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iAtUnntt  ffitbrarg 


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I 


UROLOGY 


VOLUME  I 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/urologydiseaseso01guit 


UROLOGY 

THE  DISEASES  OF  THE  URINARY 
TRACT  IN  MEN  AND  WOMEN 

A   BOOK  FOR   PRACTITIONERS  AND   STUDENTS 


BY 
RAMON   GUITERAS,   M.D.   (Harv.) 

PROFESSOR   OF    GENITO-URINARY   SURGERY,    NEW   YORK    POST-GRADUATE   MEDICAL   SCHOOL;    VISITING 
SURGEON   TO   THE   COLUMBUS  AND  POST-GRADUATE   HOSPITALS;    CONSULTING  SURGEON  TO  THE  CITY 
AND    FRENCH    HOSPITALS;    FORMERLY    PROFESSOR    OF    ANATOMY,    OPERATIVE    SURGERY    AND 
GYNECOLOGY.  POST-GRADUATE  MEDICAL  SCHOOI<,  AND  VISITIN&  SURGEON^  IN   THE   DEPART- 
MENT  OF    GENITO-URINARY   CiSEASfiS  AND  GYNECOLOGY,    NEW   YORK   CITY   HOSPITAL  ; 
MEMBER   OF    THE    AMERICAN    MEDICAL   ASSOCIATION,    THE   AMERICAN   UROLOGICAL 
ASSOCIATION,   THE   FRENCH   UROLOGipAL   ASSOCIA-TION,  THE   AMERICAN-PUBLIC 
HEALTH   ASSOCIATION,    THE   AMERICAN   ASSOCIATION    OF  "GENITO-URINARY 
SURGEONS,  THE  AMERICAN  ASSOCIATION  OF  OBSTETRICIANS  AND  GYNE- 
COLOGISTS,    THE    ASSOCIATION    OF    MILITARY    SURGEONS    OF    THE 
UNITED  STATES,  THE  AMERICAN  SOCIETY  OF  TROPICAL  MEDI- 
CINE,   THE    NEW    YORK    ACADEMY    OF    MEDICINE,    AND 
THE    HARVARD    MEDICAL    SOCIETY 


WITH  NINE  HUNDRED   AND  FORTY-THREE  ILLUSTRATIONS  IN  TEXT 

AND   SEVEN  PLATES 


VOLUME   I 


NEW     YORK     AND     LONDON 
D.    APPLETON     AND     COMPANY 

1912 


PRINTED   IN 
NEW  YORK,    V.   S.    A. 


Copyright,  1912,  by 
D.   APPLETON  AND  COMPANY 


TO    MY    TEACHERS 


HENRY   J.    BIGELOW 
THEODOR   BILLROTH 
ERNEST   FINGER 
FELIX  GUYON 
JAMES   E.    KELLY 
PRINCE   A.    MORROW 


FESSENDEN   N,    OTIS 
FREDERICK   R.    STURGIS 
ROBERT   W.    TAYLOR 
ROBERT   ULTZMANN 
LEOPOLD   VON   DITTEL 
ERNEST   VON   BERGMANN 


THIS    WORK    IS    DEDICATED 

AS    A    TOKEN    OF    RESPECT,    ESTEEM 

AND    GRATITUDE 


PKEF ACE 


This  work  on  Urology  includes  all  the  diseases  of  the  urinary  tract,  both 
medical  and  surgical,  in  men  and  women.  The  upper  part  of  the  urinary 
tract,  the  kidneys  and  ureters,  is  practically  the  same  in  both  sexes.  The 
middle  part,  the  bladder,  is  also  the  same,  although  its  relations  are  different, 
and,  whereas  bladder  troubles  in  men  are  principally  due  to  intravesical  causes 
and  obstructions  in  the  prostate  and  urethra,  the  troubles  in  women  are  gen- 
erally due  to  extravesical  causes  in  the  pelvis.  It  is  obvious,  therefore,  that 
it  is  the  lower  third  of  the  urinary  tract,  the  urethra,  which  principally  differs 
in  men  and  women. 

In  men  it  has  been  thought  advisable  to  consider  the  diseases  of  the  genital 
tract  together  with  the  urinary,  as  the  genital  tract  empties  into  the  prostatic 
urethra  and  from  this  point  to  the  external  urinary  meatus  the  two  tracts  are 
in  common.  In  women,  on  the  other  hand,  the  urinary  and  genital  tracts  are 
separated  from  each  other  throughout  their  entire  extent,  meeting  externally 
at  the  urogenital  sinus  in  the  vestibule.  The  internal  genital  organs  are,  how- 
ever, in  close  enough  contact  with  the  bladder  to  give  rise  to  many  disagreeable 
urinary  symptoms,  most  of  which  have  been  carefully  considered.  If  an  attempt 
were  made  to  consider  the  genital  tract  of  the  female  as  thoroughly  as  that  of 
the  male,  it  w^ould  necessarily  embrace  gynecology,  wdiich  is  not  within  the 
scope  of  this  work. 

It  has  been  my  aim  in  writing  the  text  to  consider  principally  cause,  diag- 
nosis and  treatment  and  not  to  go  as  deeply  into  pathology  as  many  writers  do. 
The  illustrations  were  chosen  to  show  certain  pathological  conditions  and  to 
illustrate  the  steps  of  operations,  and,  excepting  the  purely  anatomical  and 
pathological  drawings  of  specimens,  they  are  principally  diagrammatic  and 
schematic. 

The  first  part  of  the  book  is  preparatory  to  the  second.  It  contains  the 
anatomy  of  the  urinary  organs  in  the  male  and  female  and  the  laboratory 
methods  of  examining  the  urine,  discharges  and  blood.  The  dift'erent  varieties 
of  offices  for  this  kind  of  work  are  then  considered  with  their  equipment,  the 
instruments  and  apparatus  recommended  and  the  methods  of  sterilization  of 
the  apparatus  and  instruments.  The  technique  employed  in  using  the  apparatus 
and  the  general  instruments  that  compose  the  armamcutariiim  of  the  urinary 
surgeon  as  well  as  the  special  instruments,  such  as  the  urethroscope  and  cysto- 


viii  PREFACE 

scoiie,  is  carefully  described.  A  lengthy  description  of  the  general  and  special 
uriiiarv  symptoms  and  disturbances  of  urination  are  then  entered  into,  and 
urinary  fever  is  thoroughly  discussed. 

The  history  and  examination  of  the  patient,  showing  the  manner  of  arriv- 
ing at  a  diagnosis,  are  then  taken  up.  This  is  followed  by  a  chapter  on  uro- 
looical  therapeutics  in  which  drugs,  exercise,  diet  and  the  use  of  water,  inter- 
nally and  externally,  as  w^ell  as  by  rectum,  intravenous  injections  and  hypo- 
dermoclysis,  are  fully  considered.  Asepsis  and  antisepsis  and  general  and  local 
anesthesia,  such  as  are  used  in  the  various  urological  operations,  are  also  care- 
fully described.  A  small  section  on  the  diseases  of  metabolism  is  here  brouglit 
in  and  is  a  valuable  addition  to  the  work. 

The  second  part  of  the  work  is  principally  clinical  and  operative,  and  the 
diseases  of  the  various  organs  of  the  urinary  tract,  the  kidneys,  ureters,  bladder, 
prostate,  urethra  and  the  genital  organs  in  the  male  have  been  taken  up  seriatim; 
and  finally  a  chapter  on  lues  was  added.  The  most  modern  methods  of  exami- 
nation of  the  patient  and  diagnosis  are  here  described  in  great  detail.  The  med- 
ical and  palliative  treatment  of  diseases  have,  however,  been  gone  into  as  care- 
fully as  the  surgical,  and  the  details  of  such  treatment  are  thoroughly  explained. 
Lengthy  historical  data  have  been  omitted  and  statistics  have  not  been  recorded 
and  (pioted  fully.  As  the  object  of  the  book  has  been  to  make  it  a  comprehen- 
sive w^ork  for  the  practitioner,  the  bibliography  has  not  been  given  gTeat  promi- 
nence. 

Most  of  the  teachings  in  the  book  are  the  same  as  I  have  advocated  in  my 
lectures  during  the  last  twelve  years.  They  are  my  own  views  on  the  subject, 
some  original  and  others  taken  from  the  teachings  and  wa-itings  of  others  that 
appeal  to  me  as  sound  and  worthy  of  recommendation. 

Having  tauciit  in  the  jSTew  York  Post-Graduate  Medical  School  and  Hos- 
pital  for  over  twenty  years,  I  believe  I  understand  the  requirements  of  the  gen- 
eral practitioner,  and  therefore,  after  repeated  requests  from  many  students,  I 
have  endeavored  to  present  the  subject  in  a  way  which  I  believe  will  be  satisfac- 
tory to  them. 

I  wish  to  thank  Dr.  H.  T.  Brooks,  Dr.  Faxton  Gardner,  Mr.  K.  Iv.  Bosse, 
Dr.  David  Geiringer  and  Dr.  F.  Bobbins  for  their  assistance  in  the  text,  and 
Dr.  David  Geiringer  for  the  illustrations  he  has  made. 

For  the  remaining  illustrations  I  wish  to  thank  the  various  authors  whose 
names  appear  on  the  legends.  If  in  any  case  I  have  not  given  credit  w^here  it 
is  due,  it  is  on  account  of  being  doubtful  whose  name  to  inscribe.  I  wish  par- 
ticularly to  thank  Drs.  Ashton,  Corner,  Deaver,  Kelly,  Lewis,  Lydston,  Luys, 
Manson,  Wallace,  Watson  and  Cunningham  and  White  and  Martin  for  the  kind 
permission  to  use  their  illustrations. 

Ramon  Guiteras. 

80  Madison  Avenue,  New  York  City. 


CONTENTS 


VOLUME    I 

CHAPTER  PAGE 

I. — History  of  Diseases  of  the  Urinary  Tract 1 

II. — The  Anatomy  of  the  Urinary  and  Genito-Urinary  Tract    ....  9 

III.— The  Urine 70 

IV.: — Discharges • 117 

V. — The  Blood  in  Relation  to  Urology 132 

VI. — Urological  Equipment 137 

VII. — Sterilization  of  Instruments  and  Apparatus 153 

VIII. — Technique  of  Instrumentation 163 

IX. — Urethroscopy 188 

X. — Cystoscopy 198 

XI. — Special  Urinary  Symptoms 239 

XII. — Urinary  Fever  (Catheter  Fever),  Urinary  Infection 289 

XIII. — The  History  of  the  Case 297 

XIV. — General  Symptoms 304 

XV. — Examination  of  Patients 308 

XVI. — Urological  Therapeutics 323 

XVII. — Anesthesia  in  Urology 350 

XVIII. — Diseases  of  Metabolism 358 

XIX. — Methods  of  Examining  the  Kidney 369 

XX. — Anomalies  of  the  Kidney 383 

XXI. — Kidney  Injuries 390 

XXII. — Movable  Kidney 403 

XXIII. — Nonsuppurative  Nephritis         . 418 

XXIV.— Uremia       .        '. 440 

XXV. — Chronic  Suppupative  Diseases  of  the  Kid.ney 453 

XXVI. — Tumors  of  the  Kidney 480 

XXVII. — Cysts    of    the    Kidney 492 

XXVIII. — Nephrolithiasis 499 

XXIX. — Tuberculosis  of  the  Kidney     . 525 

XXX. — Hydronephrosis 560 

XXXI. — Operative    Surgery   ok    pjik    Kidney 570 

XXXII. — The  Ureters 622 

XXXIII. — Operations  on   the  Ureter 646 

ix 


LIST   OF  PLATES 


VOLUME      I  FACING 

PAGE 

Plate  I. — Indican  Color  Reaction  in  Ubine 80 

Plate  II. — Bacteria  Found  in  the  Urine 110 

Plate  III. — Bacteria,  Showing  the  Opsonic  Action  Increased  by  Proper  Adminis- 
tration OF  Bacterial  Vaccines 112 

Plate  IV. — Urethroscopic   Conditions 192 

Plate  V. — Urethroscopic  Conditions 194 

Plate  VI. — Shreds  and  Formations  Passed  in  the  First  Urine  without  Massage  .  310 

Plate  VII. — Formations  Coming  from  the  Vesicles  after  Massage       ....  318 


LIST  OF  ILLUSTEATIONS  IN  TEXT 


VOLUME    I 


FIG.  PAGE 

1. — Anterior  view  of  the  opened  genito-urinary  tract  in  the  male 10 

2. — Posterior  view  of  the  genito-urinary  tract  in  the  male 10 

3. — Posterior  view  of  the  relations  of  the  genital  and  urinary  organs  in  the  male  at 

the   back    of   the   bladder 11 

4. — Anterior  view  of  the  genito-urinary  tract  in  the  female 12 

5. — Posterior  view  of  the  genito-urinary  tract  in  the  female 12 

6. — Upper  and  middle  portions  of  the  virinary  tract  of  the  kidney 13 

7. — Lower  urinary  tract  in  the  male  on   sagittal   section,   and  also  the   internal  and 

external  genital  organs 13 

8. — Genital  organs  and  lower  urinary  tract  in  the  female  on  sagittal  section       .        .  14 

9. — Genito-urinary  sinus  in  the  male 15 

10. — Genito-urinary   sinus   in   the   female 15 

11. — Anterior  view  of  the  bony  skeleton  of  the  part  of  the  body  in  which  the  urinary 

tract  is  lodged 16 

12. — Posterior  view  of  the  bony  framework  enclosing  the  urinary  tract   ....  17 
13. — Space   occupied  by  the   urinary  tract   after   it   has   been   lined   with   its   muscular 

layer       .        .     ' 18 

14. — The  ligaments  and  muscles  helping  to  form  the  pelvic  floor 19 

15. — View  of  the  right  side  of  the  pelvic  cavity  as  seen  after  a  sagittal  section       .        .  21 

16. — The  pelvic  floor  looking  in  from  above 22 

17. — View  of  the  internal  genitals  and  the  pelvic  fascia  in  the  male  as  seen  from  be- 
hind          23 

18. — Extraperitoneal  sagittal  section  of  the  body  to  the  left  of  the  median  line       .        .  24 
19. — jMuscular  layer  of  the  perineum  on  the  right  side  after  the  removal  of  the  super- 
ficial fascia  and  on  the  left  side  after  removing  the  muscular  layer       ...  26 
20. — Anterior  perineal  triangle  after  the  removal  of  the  muscles,  the  corpus  spongeosum 

and  the  corpora  cavernosa  covering  it 27 

21. — The  outer  layer  of  the  triangular  ligament  of  the  right  side,  and  on  tlie  left  the 

space  between  the   two   layers  of  the  ligament .        .28 

22. — The  male  perineum  after  the  removal  of  the  deep  layer  of  the  triangular  ligament  29 

23. — The  perineum  in  the  female  after  the  removal  of  the   labia 30 

24. — Anterior  layer  of  the  triangular  ligament  in  the  female,  after  the  removal  of  the 

external    genitals,    the    superficial    fascia    and    muscles 31 

25. — The  deep  layer  of  muscles  forming  the  fioor  of  the  pehis  in  the   feiiialo  from  the 

outside 32 

26. — The  posterior  surfaces  of  the  kidneys  and  their  relations  to  the  ribs   ....  33 
27. — The  relation  of  the  kidneys  and  suprarenal  capsules  to  the  soft  tissues   in   front 

of   them 34 

28. — The  relation  of  the  kidneys  to  the  soft  tissues  behind  them 35 

29. — Median  vertical   (sagittal)   section  of  the  right  kidney 35 

30. — The  renal  fascia  after  a  sagittal  incision  through  the  kidney 36 

xiii 


xiv  l^lST    OF   ILLUSTKATIONS   IN   TEXT 

I'l^-  PACK 

31. — The  renal  fascia  after  a  liori/.oiilal   iiu-iwioii  tlirougli  tlie  kidney 37 

32. — Sagittal    section    of    the    kiiliicy 37 

33. — Malpighian   corpuscle 38 

34. — Scheme  of  the  renal  tubes  and  blood  vessels 38 

35. — The  renal  artery  and  its   branches 39 

30. — Schematic  drawing  showing  the  theory  of  the  anangenient  of  the  vascular  arches 

over   the   pyramids 40 

37. — The  relations  of  the  ureter  to  the  inferior  pole  of  the  kidney  and  to  the  blood  ves- 
sels  of  this   region 41 

38. — A  sagittal  section  of  the  pelvis  to  the  left  of  the  median  line  showing  the  ureter 

outside   of   the   peritoneum 42 

39. — The  relations  of  the  ureter  to  the  pelvic  tissues 43 

40. — Ureter   passing  through   the   wall   of   the   bladder 43 

41. — Schematic  drawing  of  the  relations  of  the  ureter  to  the  neck  of  the  uterus  and  its 

vessels. 44 

42. — Shape   of   the   right   ureter 44 

43. — Bladder  on  sagittal  section,  showing  its  apex  and  base 45 

44. — Bladder    on    vertical    transverse    section,    showing    the    trigone    and    the    urethral 

orifices. 46 

45. — The  peritoneal  reflection  on  the  side  of  tlie   bladder 47 

46. — Diagrammatic  drawing  of  the  upper  surface  of  the  bladder  in  the  male     ...  47 

47. — The  upper  surface  of  the  bladder  in  the  female  as  seen  from  above   .        .        .     •  .  48 

48. — Diagrammatic  drawing  showing  the  base  and  sides  of  a  dilated  bladder  from  below  49 

49. — Change  in  the  shape  of  the  bladder  while  filling 49 

50. — Longitudinal  muscular  fibers  of  the  bladder  wall 49 

51. — Middle  or  circular  layer  of  the  muscular  wall  of  the  bladder 50 

52. — Deep   layer  of   the  bladder  wall 50 

53. — ^Veins  in  the,  male  pelvis  connected  with  the  bladder 51 

54. — Veins    about    a    female    bladder 52 

55. — Male  urethra  from  the  neck  of  the  bladder  to  the  external  urinary  meatus       .        .  52 

56. — Curves  of  the  urethra  when  the  organ  is  flaccid,  also  the  fixed  portion  of  the  canal  53 
57. — Curve  of  the  urethra  when  the  penis  is  erect  or  held  in  jjosition  for  the  passage 

of  instruments 53 

58. — Membranous  urethra  arid  its  relation  to  the  triangular  ligament       ....  54 
59. — Genito-urinary  sinus  in  the  male,  the  prostate  having  been  opened  anteriorly  into 

the  urethra  and  its  lateral  lobes  retracted '.54 

60. — The  natural  dilatations  and  narrowings  of  the  urethra 55 

61. — Transverse  vertical   (coronal)   section  through  the  female  urethra       ....  56 

62. — Cowper's    glands 57 

63. — Vertical  transverse  (coronal)   cut  through  the  scrotum  and  penis   (schematic) .        .  57 

64. — The  tunica  vaginalis  opened,  exposing  the  testis 58 

65. — Schematic  drawing,  showing  the  anatomical   arrangement   of  the   tubules   in   the 

testicle    and    the    epididymis 59 

66. — Vertical  section  (sagittal)   of  the  testis  and  epididymis,  showing  the  line  of  reflec- 
tion of  the  visceral  layer  of  the  tunica  vaginalis,  the  timica  albuginea  with  its 

septa,  the  rete  testis  mediastinum,  the  epididymus  and  vas  deferens   ...  60 

67. — Blood  supply  of  the  testis  and  cord 60 

68. — Coverings  of  the  testicle,  seen  from  in  front 61 

69. — The  A'as  deferens  extending  through  the  inguinal  canal  and  along  the  side  of  the 

bladder   to    the   ejaculatory   ducts 62 

70. — Profile   view   of  the    side    of   the   unopened   prostate 64 

71. — The  lobes  of  the  prostate  and  the  perineal  fascias 65 

72. — Sagittal  section  through  the  prostate,  a  little  to  the  left  of  the  median  line     .        ,  66 

73. — Penile   urethra  in  the   state   of   repose    and   erection 67 

74.— Roots    of    the    penis 67 


LIST   OF   ILLUSTRATIONS    IN   TEXT  xv 


FIG. 


PAGE 

75. — Manner  of  union  of  the  anterior  end  of  tlie  cor2)ora  cavernosa  with  the  glans       .  08 

76. — The    end    of    the   penis 68 

77. — Urine    analysis   chart 72 

78. — Squibbs   urinometer   with   thermometer   and  cylinder 74 

79.— Saxe's   urinopyknometer   and   cylinder 75 

80. — Esbach's  albuminometer 77 

81. — The  Laurent  i^enumbra  polarizing  saccharometer -  .        .        .80 

82. — Lohnstein's    saccharometer    for    undiluted    urine 82 

83. — Einhorn's  saccharometer 82 

84. — Doremus    ureometer 84 

85. — Doremus   ureometer,  improved  form 84 

86. — Ruhemann's  uricometer  for  the  rapid  estimation  of  uric  acid 85 

87. — Hand   centrifuge 92 

88.— Water   centrifuge 92 

89. — The  Purdy   electric  centrifuge 93 

90. — Crystals   of   uric   acid 94 

91,  92. — Unusual    forms    of    uric    acid 95 

93. — Crystals  of  ammonium  urates 95 

94. — Calcium  oxalate   crystals 96 

95. — Crystals  of   ammonium  magnesium  phosphate 96 

96. — Feathery   form  of  triple  phosphates 97 

97. — Crystals   of  calcium  sulphate 97 

98. — Leucin   crystals 98 

99.— Leucin  and  tyrosin   crystals 98 

100.— Crystals    of    cystin 99 

101. — Blood  cells  in  the  urine 99 

102. — Pus   cells  in  the   urine 99 

103. — Epithelial    cells    of    genito-urinary    tract .        .        .  101 

104. — Hyaline    casts 105 

105. — Granular   casts 105 

100.— Epithelial  casts 106 

107.— Blood  casts 106 

108.— Pus    casts 107 

109. — Fatty    and    other    casts 107 

110. — Types  of  casts  with  a  waxy  matrix 107 

111. — Cylindroids  or   false  casts 108 

112. — Manner  of  holding  the  slide  in  taking  a  specimen  of  urethral  discharge  in  the  male  117 

113. — Method  of  obtaining  a  specimen  from  the  male  urethra 118 

114. — Platinvim  wire  to  be  passed  down  the  urethra  to  take  some  discharge  from  its  walls  118 

115. — Forcing  the  discharge  out  of  the  female  urethra 119 

116. — Smears   on   slides 119 

117.— The   slides  together 119 

118. — Spermatic   or   Bottcher's   crystals 120 

119. — Spirocheta    pallida 122 

119. — A  spirocheta  as  seen  by  Goldhorn  stain 122 

120. — Reflecting   condenser 123 

121. — Reflecting   condenser 124 

122. — Electrical  arc  lamp  with  hand  feed  for  a  current  of  4  amperes 124 

123. — Plan  of  an  office  of  one  room  with  waiting  room 137 

124. — Plan  of  an   office  of   two   rooms  with   waiting   room 138 

125. — Plan  of  an  office  of  three  rooms  with  waiting  room 139 

120. — Tabic  in  the  examining  room  with  glassware  used  in  examinations     ....  143 

127. — Counterbalance  table  in  the  position  for  examination  of  male  patients     .        .        .  144 
128. — Different  positions  in  which  the  patient  can  be  placed  in  examining  the  abdominal 

organS;,  especially  in  kidney  cases 145 


xvi  LIST   OF   ILLUSTKATIONS   IN   TEXT 

FIG.  PAGE 

129. — Counterbalance  table  with  a  douche-pan  on  it 145 

130. — Allison  table  in  the  cystoscopic  position 147 

131. — Appointment    form 148 

132. — Three  vertical  liles  in  which  the  envelopes  containing  the  patients'  histories  and 

correspondence   are    kept 149 

133. — Plan   of   the   clinic   at   the   New   York   Post-Graduate    Medical    School     .        .        .  1.50 

134. — Willy  Meyer  steam  sterilizer  for  the  sterilization  of  dressings  and  instruments       .  154 

135. — Rochester  sterilizer,  steam  and  dry  heat 154 

13G. — Schering-Glatz    formalin   sterilizer,   used   principally    for   woven    catheters,   piston 

syringes   and  cystoscopes 155 

137. — Snell's  formalin  sterilizer  for  sterilizing  all  catheters,  but  especially  ureteral       .  157 

138. — Method  of  flushing  out  catheters  employed  in  author's  office 158 

139. — Catheter  and  catheter  tube 159 

140. — Glass   sterilizing  tubes  with  hollow  rubber   stoppers   containing   formalin       .        .  159 

141. — Straight  catheter   with  single  eye 163 

142. — Elbowed  catheter   with  the   eye   on  the   side 163 

143. — Curved    catheter    of    the    woven    variety 163 

144. — Straight    olive-tipped    woven   catheter 103 

145. — Bi-coud6  woven  catheter .        .        .  163 

146. — Straight  rubber  catheter  with  velvet  woven  eye 164 

147. — Elbowed  soft  rubber  catheter  with  eye  on  the  side 164 

148.— Metal  catheter 164 

149.— Nelaton   catheter 165 

150. — Retained  catheter .  167 

150a. — A  more  secure  method  of  holding  a  retained  catheter 167 

151. — Malecot's   catheter. 167 

152. — Another   type  of   Malecot's   catheter 167 

153. — Pezzer's    catheter 167 

154. — Another  type  of  Pezzer's  catheter 167 

155. — Glass  urinal  between  legs 168 

156. — Relative   position   of   meatus    and   nozzle   of   the   syringe 169 

157. — Manner  of  holding  the  nozzle  of  the  syringe  in  the  urethra 169 

158. — How  the  solution  is  held  in  the  urethra 169 

159. — A    large    piston    syringe    (bladder    syringe)    used    for    washing   out    the    bladder 

through    a    catheter 170 

160. — Cut-off,  nozzle  tip  and  shield  with  a  tube  passing  to  a  douche  jar  ....  170 
161. — ^Author's  methods  of  suspending  douche  jars  for  irrigations  in  office,  hospital  and 

clinic 171 

162. — ^Author's  apparatus  for  irrigating  urethra  and  bladder  by  hydrostatic  pressure       .  172 

163. — Irrigating  Kollmann   dilator 173 

164. — Guyon's  instillating  syringe 174 

165. — Manner  of  giving  an  instillation  of  the  urethra  with  the  Guyon  instillator       .        .  174 

166. — Ultzmann's    instillating    syringe 175 

167. — Manner  of  injecting  the  posterior  urethra  by  means  of  the  Ultzmann  instillator    .  175 

168. — Curves  of  sounds  recommended 176 

169. — French   (Charrifere)   sound  scale,  compared  with  English  measurement       .        .        .  176 

170. — Sound  curve  preferred  by  author '  .        .        .177 

171. — First    step    of   passing   a    sound 177 

172. — Second  step  of  passing  a  sound 178 

173. — Third  step  of  passing  a  sound 178 

174. — Benique  sound   with   and  without   filiform   guide 179 

175. — First  step  of  passing  a  Benique  sound 179 

176. — Second  step  of  passing  a  Benique  sound 180 

177. — Third  step  of  passing  a  Benique   sovmd 181 

178. — Fourth  step  of  passing  a  Benique  sound 181 


LIST    OF   ILLUSTRATIONS    IN    TEXT  xvii 

ma.  PAOB 

179. — Oberliinder    dilators 182 

180. — Kollmann's   dilators 183 

181. — Blades  of  a  Kollmann  dilator,  opened  and  closed 184 

182,  183. — Rubber   sheaths  drawn   over  the  dilators 185 

184. — Kollmann   irrigating  dilator 185 

185. — Guiteras  urethroscope. 188 

18G. — Light   carrier   for  the   Guiteras   urethroscope 189 

187. — Portable    battery    for    the    Guiteras    urethroscope 189 

188. — Wappler's  controller  for  urethroscopy  and  cystoscopy 100 

189. — Case    of    intraurethral    instruments 191 

189a. — Urethra  probe 191 

1896. — Cannula  used  for  injecting  glands  and  follicles 191 

189c. — Urethral    knives 191 

189ri. — Gruenfell's    polypus    snare 191 

190. — Swinburne's    posterior    urethroscope 192 

191. — The  Braun-Buerger  cysto-urethroscope 192 

192. — Manner  of   introducing  the  urethroscope 193 

193. — Swabbing    out    the    urethra 193 

194. — Position   in   examining  the   anterior   urethra 194 

195. — Position  in  examining  the  posterior  urethra 195 

196. — Brenner's  observation  and  catheterizing  eystoscope 200 

197. — Nitze's  observation  eystoscope 201 

198. — Nitze's    irrigating    eystoscope 201 

199. — Nitze's  operating  eystoscope,  showing  the  snare  and  lithotrite 202 

200. — Nitze-Albarran    catheterizing    eystoscope 203 

201. — A   direct   air   eystoscope   of   American   make       .        .        . 204 

202. — The  Brown  direct  eystoscope 205 

203. — BierhoflF's  indirect  catheterizing  eystoscope 205 

204. — Bransford  Lewis   eystoscope 206 

205. — Guiteras   teaching  eystoscope 208 

206. — Portable  table  used  for  cystoscopy  in  the  clinic  and  at  private  houses       .        .        .  211 

207. — Patient's  position  for  cystoscopy  on  Allison  table 213 

208. — Washing  out  the  bladder  through  the  urethroscope,  first  step 214 

209. — Washing  out  the  bladder  through  the  urethroscope,  second  step 214 

210. — Looking   into  the  bladder 215 

211. — Air    cystoscopy 215 

212. — The  eystoscope  introduced  into  the  bladder 219 

212a. — Inspection   of  the  bladder  with  the   indirect   eystoscope 219 

212&. — Inspection  of  the  bladder  with  the  direct  eystoscope           220 

213. — Phantom  bladder  for  practicing  cystoscopy  and  ureteral  catheterization   .        .        .  228 

214. — Catheterization  of  the  ureters 228 

215. — The  same  position  as  in  Fig.  214,  to  show  the  position  of  the  hands  in  catheteriza- 
tion   229 

216. — Catheterization  of  the  ureters  by  the  direct  method 230 

217. — Catheterization  of  the  ureters  by  the  indirect  method 231 

218,  219. — Catheterization  of  the  ureters,  the  catheters  in  situ       .        .        .        .        .        .  232 

220. — Diagrams  of  bladder  used  for  keeping  records 236 

221. — The  outline  of  the  abdomen  in  a  case  of  retention 258 

222. — The  Blasucci  catheter,  first  step  of  catheterization 261 

223. — The  Blasucci  catheter,  second  step  of  catheterization 262 

224. — The  Blasucci  catheter,  third  step  of  catheterization 263 

225. — Paracentesis  of  the  bladder 264 

226. — The  method  of  wearing  a  urinal 270 

227.— Chart  of   acute   urinary   fever 292 

228. — Chart   of  acute   recurring   urinary    fever 292 


xviii  LIST   OF   ILLUSTEATIONS    IN   TEXT 

via.  PAGE 

229. — Chart  of  chronic  urinary   fever 293 

230.— Male  history  card 298 

231.— Female  history  card 299 

232. — Patient  lying  at  full  length,  first  step  in  the  examination  of  the  male       .        .        .  309 

233. — Examination  of  the  kidneys,  the  patient  lying  flat 310 

234. — Examination  of  the  kidneys,  the  patient  in  the  sitting  posture 310 

235. — Examining  the  kidney,  with  the  patient  lying  on  the  healthy  side       .        .        .        .311 

236. — Position  for  examining  the  female  genitals  and  urethra 313 

237. — Male   patient    urinating  in   a   glass   cylinder 313 

238. — The  preparation  of  the  finger  prior  to  rectal  examination 314 

239. — Rectal  examination  of  the  prostate  and  vesicles 315 

240. — Massage  of  the  prostate 316 

241. — Examining  the  urethra  with  the  bougie  a,  boule 319 

242.— Filiform    bougies 319 

243. — The   examiner   looking  through   the   urethroscope 320 

244. — Method  of  obtaining  specimens  of  urine  from  female  patients 321 

245,  246. — Abdominal  exercise 330 

247. — Back   exercises 331 

248. — Front   exercises 332 

249-252. — Chest    and    arm    exercise 333,  334 

253. — Loin   exercises 335 

254. — Recto-genital   tube 341 

255. — Rectal  irrigations,  patient  in  bath   tub 342 

256. — Rectal  irrigations,  patient  reclining  in  chair 342 

257. — Hypodermoclysis 347 

258.^Intravenous  injection,  first   step 348 

259. — Intravenous  injection,  second  step 348 

260. — Intravenous    injection,    third    step 349 

261. — Syringe  for  local  anesthesia 354 

262. — Method  of  holding  the  syringe ■ 355 

263. — Method  of  making  the  blebs  in  intradermic  injections 355 

264. — The  subcutaneous  method  of  anesthetizing  an  area  to  be  operated  upon       .        .  356 

265. — Minute  tubercular  abscesses  of  a  single  asymmetrical  kidney 386 

266. — Single  asymmetrical  kidney,  8-^  inches  long,  removed  at  autopsy       ....  388 

267. — Single  asymmetrical  kidney,  markedly  convoluted,  removed  at  autopsy     .        .        .  388 

268. — Shape  of  the  abdomen  in  the  case  of  a  ruptured  kidney 395 

269. — The  rent  in  the  kidney  proper  and  pelvis  of  a  ruptured  kidney 397 

270. — Displacement  of  the  kidney,  showing  the  first,  second,  and  third  degrees  of  dis- 
placement        404 

271. — Kinking  of  the  ureter  in  displacement  of  the  kidney 405 

272. — Anterior  view  of  the  body  divided  into  three  zones,  the  upper,  middle  and  lower, 

in  people  with  movable  kidney,  as  determined  by  Harris 408 

273. — Side  view  of  the  body  and  the  lines  corresponding  to  the  antero-posterior  diam- 
eters of  the  body  index,  predisposing  to  movable  kidney 408 

274. — Pomeroy's  elastic  abdominal  support  for  patients  with  movable  kidney     .        .        .  415 

275. — Straight-front  corset  for  movable   kidney 416 

276. — How  the  corset  should  be  put  on  in  movable  kidney 416 

277a. — Wide  strips  of  adhesive  plaster  for  supporting  abdomen 416 

2776. — The  adhesive  plaster  strips  applied 417 

278. — Kidney  pad  to  be  buttoned  on  the  back  of  a  vest  as  a  protection  for  nephrctics  432 

279.— Southey's   tubes 437 

280. — Bleeding  the   patient   in   uremia 451 

281. — Pyelo-nephritis 457 

282. — Pyonephrosis,   showing  enlargement   of  the    kidneys   and   their  pelvis   and   kinked 

ureters           460 


LIST    OF    J  LLUSTKATIONS    IN    TEXT  xix 


via 


PAGE 

283. — Cross  section  of  a  calculus  pyonephrotic  kidney,  7i  inches  long 4G1 

284.— Bulge  in  perinephritic  abscess  in  left  side  of  loin,  front  view 468 

285. — Characteristic  bulge  in  a  perinephritic  abscess  on  the  left  side,  back  view       .        .  4G9 

286.— Posterior  surface  of  left  kidney  in  a  case  of  a  tubercular  perinephritic  abscess       .  470 

287. — Posterior  surface  of  tuberculous  kidney  in  a  case  of  perinephritic  abscess       .        .  471 
288. — Longitudinal    section   of   same   kidney,   showing  contracted   pelvis   now   not   much 

larger   than   the   vu-eter 471 

289. — A  bulging  of  pus  in  the  groin  and  an  opening  in  the  thigh  and  groin  made  to  drain 

a  perinephritic  abscess 472 

290. — A  sharp-pointed  calculus  that  v^^as  found  sticking  through  the  wall  of  the  kidney 

in  a  case  of  perinephritis 473 

291. — Multiple  disseminated  abscesses  of  kidney 475 

292.— Chronic  parenchymatous  nephritis  with  acute  exacerbation   and   suppurating   foci  477 

293. — Chronic  interstitial  nephritis,  the  other  kidney  in  the  case 477 

294. — Carcinoma  of   the   kidney 482 

295. — Sarcoma  of  the   kidney 483 

296. — Hypernephroma,   outside   view 485 

297. — Hypernephroma,  view  on  section 485 

298. — Papilloma  of  the   renal  pelvis 490 

299. — Large  serous  cyst  of  the  kidney "...  493 

300. — Two  large  polycystic  kidneys  in  the  same  individual .  494 

301. — The  larger  kidney  in  Fig.  300  on  section 495 

302.— Hydatid  cyst  of  the  kidney 497 

303. — Some  large  calculi  removed  from  a  pyonephrotic  kidney 501 

304. — A  pyonephrotic  kidney  in  a  state  of  acute  renal  retention 503 

305. — The  renal  pelvis  of  a  pyonephrotic  kidney  filled  with  five  stones  of  large  size       .  504 

30G. — A  cluster  of  stones  in  one  kidney 510 

307. — A  cluster  of  stones  in  both  kidneys 511 

308. — A  calculus  concealed  in  the  thick  mass  of  fibrous   tissue  held  open  by  the  hook 

and  not  detected  by  nephrotomy 518 

309. — A  renal  calculus  that  was  discharged  through  the  wall  of  the  kidney    .        .        .  519 

310. — Clusters  of  tubercles  on  the  outside  of  the  kidney 528 

311. — The  same  kidney  as  in  Fig.  310,  shown  in  section 528 

312. — A  ease  in   which   the   tuberculous   abscesses   have   broken   into   the   pelvis,   giving 

rise   to   pyelonephritis 529 

313. — Tuberculous  pyelonephritic  kidney 530 

314. — Tuberculous  pyonephrotic  kidney 531 

315. — A  case  of  urinary  tuberculosis  involving  both  ureters  and  both  kidneys             .        .  532 
316. — Tuberculous  kidney  in  which  the  functionating  renal  tissue  has  been  entirely  de- 
stroyed by  the  disease 533 

317. — A  vertical  section  of  a  tuberculous  kidney  removed  by  a  secondary  nephrectomy  549 

318. — Kidney   with   hydronephrosis 561 

319. — Hydronephrosis,   first    stage 563 

320. — Hydronephrosis,   second    stage 563 

321. — Hydronephrosis,  third  stage 563 

322. — Instruments  used  in  operations  on  the  kidney 571 

323. — Posterior   kidney   angle   and   triangle 572 

324. — Anterior  kidney  angle  and  triangle 572 

325. — Posterior  vertical  incision  seeri  on  the  left  and  the  short-curved   iiu-ision   on  llic 

right 573 

326. — Anterior  vertical  incision  seen  on  the  right   side  and  the   "  modified  "'   incision   on 

the   left 573 

327. — Transverse    incision 574 

328. — Long  curved  lumbar  incision,  the  position  preferred  in  renal   surgery        .        .        .  574 

329. — Oblique  lumbar  incision 574 


XX  LIST    OF   ILLUSTRATIONS    IN    TEXT 

FIG.  PAGE 

330. — Operating  table  with  a  transverse  iron  plate  running  across  it  that  can  be  elevated 

to  any  distance  for  regulating  the  patient's  position 575 

331. — Body  holder  for  preventing  the  patient  from  rolling  when  lying  on  the  side   .        .  576 

332. — The   body  holder  on  the  patient 57G 

333. — Incision  through  the  skin  and  superficial  fascia,  revealing  Pctit's  triangle       .        .  577 

334. — Incision  through  latissimus  dorsi  muscle,  showing  the  tissues  beneath   it       .        .  578 

335. — Muscles  cut  through  down  to  the  lumbar  fascia 578 

336. — Deep  lumbar  fascia  cut  through,  showing  the  fatty  capsule  of  the  kidney  .        .        .  579 

337. — Freeing   the   kidney 579 

338.— Delivery   of   kidney 580 

339. — Delivery  of  the  kidney,  the  lower  pole  first 580 

340. — Delivery  of  the  upper  pole  of  the  kidney    .        .        .  ' 581 

341. — Delivery  of  the  kidney  by  inserting  the  entire  hand  in  the  wound       .        .        .        .581 

342. — Examination  of  the  kidney  by  pyelotomy 583 

343. — Operation  for  movable  kidney;   the  fixation   sutures  are  passed  through   the   ab- 
dominal   wall 584 

344. — Operation   for   movable   kidney;    the   kidney   is    delivered   and   the    whole    of    the 

fatty   capsule  behind  the   kidney   is   cut   away 585 

345. — Operation  for  movable  kidney;  the  capsula  propria  of  the  kidney  slit  through       .  585 
346. — Operation  for  movable  kidney;  the  kidney  capsule  on  the  back  of  the  kidney  is 

reflected  halfway   to  the   hilum 585 

347. — Operation  for  movable  kidney;  the  posterior  fixation  sutures  are  passed  through 

the    doubled    capsule    of    the    kidney 586 

348. — Operation  for  movable  kidney;  the  anterior  fixation  suture  is  passed  between  the 

capsule   and  cortex 587 

349. — Operation  for  movable  kidney;   the  kidney  is   pushed  back   again  into  the  renal 

fossa  and  the  fixation  sutures  are  again  passed  through  the   abdominal   wall  587 
350. — Operation  for  movable  kidney;  the  muscles  and  fasciae  of  the  abdominal  incision 
are  closed  by   interrupted   sutures,   the   fixation   sutures   are   hauled   taut    and 

tied 588 

351. — Side  view  of  the  convexity  after  anchoring  the  kidney 589 

352. — Posterior  view  after  anchoring  the  kidney 589 

353. — Anterior  view  after  anchoring  the  kidney 589 

354. — Nephrotomy;   showing  position  of  patient  and  loin   incision 591 

355. — Nephrotomy;  the  long  incision  from  pole  to  pole 592 

356. — Nephrotomy;   the  short  incision  between  the  poles 592 

357. — Nephrotomy;    catheterization    of   the   ureter    from   above 593 

358. — Method  of  passing  sutures  in  closing  the  nephrotomy  incision  in  the  kidney  .        .  594 

359. — Appearance   of  the  kidney  after  closure 594 

360. — Drainage   tube  in  position 594 

361a. — Four-tailed  bandage  for  controlling  renal  hemorrhages 596 

3616. — Four-tailed   bandage   in   place 596 

362. — Nephrostomy;  this  is  nephrotomy  plus  fixation  of  the  sides  of  the  kidney  incision 

to  those  of  the  abdominal  wall 598 

363. — Drainage    in   nephrostomy 599 

364. — Drainage    by   siphonage 599 

365. — Cup-shaped  shield  of  Watson's  apparatus  for  permanent  renal   drainage  through 

the   loin 600 

366. — The  metal  receptacle  of  Watson's  apparatus 601 

367. — Method  of  clamping  the  pedicle  and  passing  the  pedicle  ligatures  in  nephrectomy  602 

368. — Nephrectomy;  ligatures  in  place  ready  to  tie 603 

369. — Nephrectomy ;   second  ligature 603 

370. — Albarran's  method  of  securing  the  pedicle  in  a  subcapsular  nephrectomy       .        .  609 

371. — Retraction  of  the  capsule,  allowing  the  operator  to  ligate  the  pedicle  outside  of  it  609 

372. — Partial  nephrectomy 610 


LIST   OF   ILLUSTKATIONS    IN   TEXT  xxi 

Fia.  PA«B 

373a — Nephrectomy  by   morcellcment ;  the  lower  pole  amputated 611 

3736. — Nephrectomy   by   morcellcment;    the   upper   pole   amputated 611 

373c. — Nephrectomy  by  morcellement;  the  remains  of  the  istlimus  between  the  two  poles  612 

374. — Closing  of  the  wound  in  nephrectomy  by  morcellement 612 

375. — Nephrectomy  by  the  transverse  incision;  the  kidney  delivered 613 

376. — Nephrectomy  by  the  transverse  incision;  the  vascular  pedicle  clamped  .  .  .  614 
377. — Anterior  or  transperitoneal   nephrectomy;   the  peritoneal   cavity   opened  and   the 

incision  made  in  the  mesocolon 614 

378. — Anterior  or  transperitoneal  nephrectomy ;   the  kidney  being  freed  from  the  fatty 

capsule           615 

379. — Anterior  or  transperitoneal  nephrectomy ;  the  kidney  delivered  and  pedicle  clamped 

and  ligated 615 

380. — Anterior   or   transperitoneal   nephrectomy;    the    kidney    removed    and   the    wound 

closed 616 

381. — Hydronephrosis 616 

382. — Resection  of  kidney  pouch  below  the  ureter 617 

383. — Capittonage;  the  part  of  kidney  pouch  below  the  ureter  is  drawn  up  by  a  series 

of   tucks    or    reefs 618 

384. — Albarran's  method   of  suturing  in  capittonage 618 

385. — Cutting  down  the  ureteral  spur 619 

386. — Cutting  down  the  ureteral  spur;  sutures  passed  uniting  pelvic  and  ureteral  walls 

on  either  side 619 

387. — Uretero-pyeloplasty ;    the   incision 619 

388. — Uretero-pyeloplasty;   sutures  placed  so  as  to  leave  a  transverse  wound  .        .        .  620 

389. — Uretero-pyeloplasty;    sutures    ligated 620 

390. — Lateral  pelvic-ureteral  anastomosis 620 

391. — Lateral  pelvic-ureteral  anastomosis;  the  wound  united 620 

392. — Kinked  ureter  with  adhesions  amputated   below 621 

393. — Two  ureters  emptying  into  the  bladder,  coming  from  a  single  unsymmetrical  kid- 
ney on  the  right   side 622 

394. — A  double  ureter  coming  from  the  left  kidney,  as  seen  by  radiography       .        .        .  623 

395. — Vesical  ends  of  the  ureters  prolapsing  into  bladder 624 

396. — A  diverticulum  of  the  part  of  the  ureter  passing  through  the  bladder  wall       .        .  624 

397. — Ureteritis    and    associated    pyonephrosis 629 

398. — Dilatation  of  the  renal  pelvis  and  ureter  in  a  case  of  acute  ureteritis  ....  630 

399. — Papilloma  of  the   ureter 631 

400. — Cervix  with  a  cancerous  growth  that  has  involved  the  ureter  and  bladder       .        .  631 

401. — Positions  of  ureteral  calculi 633 

402. — Actual  size  of  a  stone  giving  rise  to  calculous  anuria 635 

403. — Case  of  double  ureteral  calculus 638 

404. — Tuberculosis   of   the   ureter 640 

405. — Thickening,  dilation,  ulceration  and  strictures  of  the  ureter  that  are  seen  in  Fig. 

404,    more    clearly    shown 642 

400. — Instruments  for  ureter  operations 647 

407a. — Ureterotomy  for  stone;  delivery  of  the  ureter  below  the  kidney       ....  647 

4076. — Ureterotomy  for  stone;  method  of  enlarging  the  field  prior  to  operation  .  .  647 
408. — Ureterotomy  for  stone;  exposing  the  ureter  as  it  crosses  the  pelvic  brim  and  iliac 

vessels 648 

409. — Ureterotomy  for  stone  in  the  Trendelenburg  position.     The  same  incision  is  seen 

and  two  ligatures  about  the  epigastric  artery       .        .        .        .        .        .        .        .  648 

410. — Ureterotomy  for  stone;  shows  a  deep-seated  calculus 649 

411. — Ureterotomy  for  stone;   the  delivery  of  the  calculus,  the  clamping  of  the  iireter, 

and  the  suturing  of  the  ureteral  wall 650 

412. — Ureterotomy  for  stone;  a  ureteral  catheter  as  an  aid  in  suturing  the  ureter             .  651 

413. — Incision  through  the  broad  ligament,  exposing  the  ureter  on  one  side       .        .        .  652 


xxii  LIST   OF   ILLUSTRATIONS   IN    TEXT 

FIG.  PAGE 

414. — Perineal  ureterotomy;  the  vesicle  and  the  vas  pulled  to  one  side  and  ureter  hooked 

up   and   incised   over   the   calculus 053 

415. — Patient  in  the  gj-necological  position.    An  incision  is  seen  in  the  vaginal  wall,  the 

ureter  hooked  up  and  incised  over  the  calculus 654 

41G. — Intravesical   ureterotomy.     The   bladder   opened   suprapubically ;    the   part   of   the 

bladder  wall  through  which  the  ureter  passes  and  the  stone  are  clearly  seen       .  655 

417. — Ureterotomy  for  stricture 656 

418. — Ureterorrhaphy 658 

419. — Poggi's  operation  for  a  ureteral  anastomosis 658 

420. — Van  Hook's  operation  of  lateral  anastomosis 659 

421. — Bov^e's  method  of  end-to-end  anastomosis 659 

422. — Transperitoneal    method    of    uretero-cystotomy 661 

423. — Uretero-colostomy           663 

424. — Ileo-lumbar  incision   for   nephro-ureterectomy 664 

425. — !Nephro-ureterectomy 665 

426. — Showing  Kelly's  method  of  removing  the   ureteral   stump   through  the   vagina   in 

nephro-ureterectomy 666 


UROLOGY 

•      VOLUME    I 


CHAPTER    I 
HISTORY  OF  DISEASES   OF  THE   URINARY  TRACT 

Ancient  Urology. — Diseases  of  the  urinary  tract  have  been  known  and 
treated,  both  in  a  medical  and  surgical  wav,  for  many  centuries.  Medical  treat- 
ment was  first  recorded  in  the  Papyrus  of  Ebers,  written  1550  years  b.c, 
in  which  were  given  many  prescriptions  for  their  cure.  From  this  time  until 
the  present,  various  remedies  have  been  used  internally  and  externally  by 
medical  men,  and  by  the  monks  during  the  Middle  Ages,  when  the  practice  of 
medicine  was  principally  in  their  hands. 

The  history  of  the  progress  of  surgery  has  been  interesting,  although  noth- 
ing was  written  upon  it  until  the  time  of  the  "  Ayurveda  of  Sucrutu,"  the  great 
work  of  the  Hindoos  in  India,  which  was  brought  out  about  one  thousand  years 
after  the  first  recorded  manuscript.  The  first  operation  spoken  of  in  this  later 
work  was  perineal  lithotomy,  which  was  then  performed  in  practically  the 
same  way  as  it  is  to-day.  The  Hindoos  at  this  time  were  also  treating  strictures 
by  gradual  dilation  with  sounds  of  metal  or  wood,  and  were  treating  diseases 
of  the  urethra  and  bladder  by  injections. 

Hippocrates  (about  400  b.c.)  was  the  next  great  writer.  Among  other  sub- 
jects, he  was  interested  in  vesical  calculi,  and  described  accurately  how  a  stone 
grows  gradually  from  a  nucleus.  He  thought  that  lithotomy  should  be  per- 
formed only  by  a  lithotomist.  He  was  the  first  to  be  interested  in  the  surgery 
of  the  kidney,  and  taught  that,  as  soon  as  a  swelling  appeared  in  that  region, 
it  should  be  cut  down  upon,  lie  also  wrote  on  the  subject  of  urethral  abscess  and 
cystitis,  and  was  the  first  to  point  out  the  change  in  the  urine  in  diseases  of 
the  kidney  and  bladder. 

Cornelius  Celsus,  the  gTeat  Poman  medical  writer  who  lived  at  the  licgin- 
ning  of  the  Christian  era,  was  the  next  to  write  extensively  on  urinary  dis- 
eases. He  wrote  on  urethrotomy  for  impacted  urethral  stone;  catheterization 
for  retention  of  urine,  especially  in  old  men;  vesical  calculus  and  lithotouiy, 
iut'ludiug  after-treatment;  and  the  care  of  wounds  and  fistuhv.  Perineal  ure- 
throtomy was  also  performed  for  stricture  by  the  Poman  surgeons  cue  hundred 
and  fift}^  years  later. 

1 


y'^'  HISTORY   OF   DISEASES    OF   THE   URINARY   TRACT 

Galen  was  the  next  writer  of  consequence.  lie  wrote  upon  incontinence 
and  retention  of  urine,  and  described  an  "  S-sliaped  "  or  curved  catheter  which 
he  used  for  the  relief  of  the  latter  trouble. 

Ca.'lius  Aurolianus,  at  the  beoinning-  of  the  fourth  eenturv,  was  the  next 
to  interest  hiuisclf  in  diseases  of  the  bladder.  He  used  a  stone  searcher  for 
the  diagnosis  of  vesical  calculus. 

Mediaeval  Urology. — We  thus  see  that,  in  the  beginning  of  the  Middle  Ages, 
diseases  of  the  urinary  tract  had  bfeen  treated  medically  for  two  thousand  years, 
while  surgical  interference  had  been  going  on  for  a  thousand  years.  Diseases  of 
the  urethra,  prostate,  bladder  and  kidney  were  already  known,  and  many  of  them 
had  been  operated  ujion.  It  was  strange  therefore  that  at  such  a  time  a  de- 
cadence should  have  taken  place,  that  the  practice  of  medicine  should  have 
fallen  into  the  hands  of  the  monks,  and  that  surgery  was  attended  to  by  the 
barber  and  charlatan.  This  condition  existed  until  the  fourteenth  century, 
when  scientific  surgery  again  started  up  in  Paris,  at  the  College  of  Saint  Come, 
founded  by  Jean  Pitard,  and  thence  slowly  extended  over  Europe.  The  ad- 
vances along  the  urological  line  w^ere  evidenced  by  the  discovery  of  movable 
kidney  in  1497  by  Mesure  of  Venice;  the  improvement  in  the  technique  of 
stricture  operations  by  Ambrose  Pare  and  Richard  Wiseman ;  the  works  of  Git- 
tler  of  Leipsic  on  wounds  of  the  kidney ;  the  rescue  of  lithotomy  from  the  hands 
of  the  layman  and  the  variation  of  its  technique  by  Pierre  Franco. 

Changes  of  the  urine  had  been  spoken  of  since  the  time  of  Hippocrates, 
but  the  first  w-ork  of  any  scientific  importance  was  that  of  Protospathori  in  the 
seventh  century ;  for  he  not  only  described  normal  urine,  but  also,  in  a  clear 
way,  the  various  changes  that  took  place  in  the  urine  of  disease.  Actuarius, 
a  Turk,  wrote  the  first  extensive  work  on  this  subject  in  the  twelfth  century, 
and  it  remained  an  authoritative  treatise  for  five  hundred  years. 

During  the  heyday  of  the  Salernian  School,  near  Xaples,  all  the  physicians 
were  practically  urologists,  as  they  depended  largely  upon  the  urine  for  diag- 
nosis and  prognosis,  and  the  urinal  became  the  insigTiia  of  the  physician  and 
the  emblem  of  medicine.  At  this  time,  the  examination  of  the  urine  was  re- 
sorted to,  not  only  by  the  regular  practitioner  and  the  university  graduate,  but 
also  by  the  school  of  quacks,  known  as  uromancers  or  uroscopists,  who  gravely 
inspected  urine  passed  into  a  glass  flask,  guessed  the  illness  and  temperament 
of  the  patient,  and  dispensed  miraculous  cures. 

Paracelsus  and  Van  Helmont,  in  the  latter  part  of  the  sixteenth  century, 
introduced  the  spagiric  or  so-called  analytic  methods  of  the  diagnosis  of  dis- 
ease, which  depended  on  the  proportion  in  which  the  three  elements  of  man's 
nature — mercury,  sulphur,  and  salt — occurred  in  the  urine.  Boerhaeve  and 
Bellini,  in  the  seventeenth  century,  added  to  the  study  of  urine.  Boerhaeve 
distilled  the  urine  and  weighed  the  vapors.  When  the  vaj)or  occupied  a  certain 
part  of  the  still,  it  pointed  to  disease  in  a  certain  part  of  the  body.     He  was 


MODERN    TTROLOGY  3 

tlio  first,  to  discover  tlio  si)ccific  i>,Tavity  of  urine.  Px'llini  advocated  the  study 
of  llui  uN'crage  urine  of  the  healthy  individual,  llic  amount  pAssed  and  the 
specific  gravity  as  a  standard  witli  which  the  unhealtliy  urine  slioidd  he  coni- 
jini'cd. 

In  the  latter  part  of  the  eighteenth  century,  there  Avas  a  decided  advance 
in  urinary  analysis.  Cotugno  discovered  albumin  in  the  urine  of  diseased 
kidneys  l)y  boiling  it.  Roulle  and  Cadet  discovered  urea  and  isolated  many 
.salts  of  the  urine,  and  Schule  discovered  uric  acid. 

It  will  thus  be  seen  that,  at  the  dawn  of  the  nineteenth  century,  a  good 
working  basis  existed  in  the  study  of  urinary  diseases,  especially  in  the  line  of 
urinai'v  examinations  and  the  treatment  of  urethral  and  bladder  diseases. 

Modern  Urology. — Modern  urological  history  may  be  divided  into  two 
periods,  the  first  and  second  halves  of  the  nineteenth  century,  the  first  of  which 
was  preparatory  to  the  second. 

During  the  first  half  of  the  century  the  work  was  principally  confined  to 
improving  and  elaborating  urethral  and  bladder  work,  urinary  examination, 
and  the  study  of  pathology. 

In  1805,  Bozzini  of  Frankfort,  invented  an  apparatus  for  illuminating  the 
urethra  and  bladder,  which  was  the  first  of  a  series  of  crude  attempts  that  led 
to  our  present  knowledge  of  urethroscopy  and  cystoscopy.  In  urethral  work, 
Desormeaux  in  1853  improved  the  endoscope.  Later  a  cooling  apparatus  was 
added,  which  finally  was  supplanted  by  the  mignon  or  cold  lamp  introduced 
l)y  Preston,  an  electrician  of  Rochester,  jST.  Y.,  at  about  the  dawn  of  the  twen- 
tieth century,  thus  giving  ns  the  practical  instrument  of  to-day. 

Maisonneuve  in  1853  invented  the  first  of  the  modern  urethrotomes,  which 
is  still  used  in  internal  urethrotomy  to  cut  through  small  strictures  from  the 
front  backward,  and  in  1872,  Otis  invented  his  dilating  urethrotome  for  cutting 
strictures  of  large  size  from  behind  forward.  Both  of  these,  although  there 
have  been  many  modifications,  exist  to  the  present  day.  The  dilation  of 
urethral  strictures  by  the  dilators  of  Oberliinder  and  Kollmann  have  since  then 
superseded  the  use  of  sounds  with  many  practitioners.  The  method  of  treating 
urethritis  by  the  irrigation  of  Janet,  and  numerous  new  ren^edies  for  hand  in- 
jections, have  entered  into  our  urethral  therapeutics. 

In  bladder  work,  the  efforts  to  improve  the  diagnosis  of  pathological  con- 
ditions by  vision,  led  to  the  gradual  development  of  the  illuminating  instru- 
ments, the  first  marked  improvement  being  that  of  Briick,  a  dentist,  who  called 
his  instrument  a  diaphanoscope.  Improvements  were  slow  and  nnimportam: 
until  187G,  when  ISTitze,  Brenner  and  Leiter  perfected  their  cystoscopes,  giving 
us  our  present  knowledge  of  cystoscopic  diagTiosis.  These  were  rendered  more 
practical  three  years  later  (18Tl>)  by  introduction  into  them  of  the  incan- 
descent lamp,  which  enabled  the  urologist  to  employ  it  instead  of  the  hot 
and   less   luminous   platinum   wire    hitherto    used,    with    a    cooling   apparatus. 


4  illSTORY    OF   DISEASES    OF    THE    rPJNARY    TRACT 

Further  iiii])rovement,  due  to  the  use  of  smaller  aud  colder  lamps,  ren- 
dered the  use  of  cooling  devices — irrigation  with  water  while  exauiining — 
unnecessary. 

In  bladder  surgery,  Civiale  (1817)  performed  the  first  successful  lithotrity, 
the  crushing  of  a  vesical  calculus,  with  an  instrument  wdiicli  served  as  a  pro- 
totype for  the  modern  lithotrite.  His  lithotrite  was  modified  by  Weiss,  Hodg- 
son, Ferguson  and  Sir  Henry  Thompson,  and  finally  by  Bigelow  fl.STT)  who 
combined  the  operation  with  evacuation  of  the  fragments  of  stone  by  means  of 
an  aspirator  in  one  operation,  litholapaxy.  His  evacuator  for  emptying  the 
bladder  of  the  last  fragment  of  stone  consisted  of  a  very  large  hollow  sound, 
with  a  large  eye  in  its  concavity,  connected  wdth  a  rubber  bulb,  between  which 
and  the  sound  was  a  bottle  into  which  the  fragments  fell  wdien  sucked  out  by 
squeezing  and  releasing  the  bulb.  While  suprapubic  lithotomy  in  this  country 
has  largeh^  superseded  Bigelow's  operation,  his  method  stands  to  this  day  in 
all  parts  of  the  world  as  the  j)rocedure  best  employed  for  the  removal  of  stone 
in  the  bladder  in  a  selected  class  of  cases. 

In  the  work  on  the  kidney,  that  of  Richard  Bright  (1827)  was  the  founda- 
tion of  our  present  knowledge  of  the  medical  diseases.  Bright's  investigations 
showed  that  many  patients  with  dropsy  and  albumin  in  the  urine  had  diseased 
kidneys,  and  although  Catu'gno,  the  discoverer  of  albumin,  had  made  it  known 
a  century  before  and  Allison  in  1823  had  reported  the  occurrence  of  dropsy 
with  albuminuria  in  kidney  disease.  Bright  found  the  profession  more  recep- 
tive to  scientific  advances  than  did  Catugno,  and  through  his  w^ritings  received 
such  recognition  that  the  name  of  Bright's  disease  w^as  applied  to  pathological 
conditions  of  the  kidney  accompanied  by  albuminuria.  In  1823,  Scudmore  of 
London  had  found  that  the  urine  of  patients  with  albuminuria  contained  less 
urea  than  that  of  normal  persons.  The  discovery  of  urinary  casts  by  Viglia, 
some  ten  years  after  Bright's  publication,  added  another  important  link  to 
the  chain  of  our  present  knowledge  of  urinary  findings  in  nephritis.  From 
these  early  studies  sprang  the  elaborate  researches  of  later  years,  as  recorded 
in  the  text-books  of  Johnson  ("Diseases  of  the  Kidneys,"  London,  1852),  Jo- 
hann  Fogel  (1856),  Rosenstein  (18G3),  Senator  (1896)  and  others. 

In  renal  surgery,  Paeslee  performed  the  first  nephrectomy  (1868)  by  ac- 
cident, in  a  case  the  diagnosis  of  which  had  been  an  ovarian  tumor.  Simon, 
the  following  year,  removed  the  first  kidney  purposely  in  a  case  of  calculous 
pyonephrosis,  and  took  advantage  of  this  step  to  write  his  important  monograph 
on  the  kidney,  in  which  he  gave  a  definite  classification  of  the  surgical 
affections  of  the  organ,  thus  stamping  them  formally  for  the  first  time  as 
surgical. 

Catheterization  of  the  ureters,  which  now  is  one  of  the  most  important 
urological  procedures,  owes  its  birth  to  the  efforts  of  Pawdik  and  Bozeman, 
who  were  the  first  to  catheterize  the  ureters  in  women.     The  development  of 


MODERN    UROLOGY  5 

this  important  prorodnro  was,  liowevor,  due  to  the  cystoscopists.  They  added  a 
eoinpartiiient  to  their  cystoscopes  for  the  passage  of  a  small  woven  catheter, 
tlien,  hy  looking  at  the  month  of  the  nreter,  they  conld  pnsh  the  catheter  into 
the  bladder  nntil  its  end  entered  the  nreter.  The  first  catheterizing  cystoscopic 
instrument  was  that  of  Brenner  (1892),  then  followed  tliose  of  Xitze  (1805), 
Casper  (ISilf)),  Albarran  (1897),  etc.  Later  they  addc(]  to  their  iiistrmnents 
a  double  catheterizing  apparatus  which  enabled  them  to  cathctcrize  both  ureters 
at  the  same  time. 

One  of  the  most  important  discoveries  in  urology,  as  in  all  other  diseases, 
was  the  rule  of  the  microorganism  as  the  causative  agent  of  fermentation,  de- 
composition and  disease,  by  Louis  Pasteur,  described  in  a  work  called  "  La 
Generation  Spontanee,"  which  appeared  in  1859.  He  took  up  in  particular 
the  Micrococcus  nrea^,  which  causes  urinary  decomposition  by  splitting  up  urea 
into  ammonia  and  other  by-products,  and  suggested  that  the  bacteria  enter  the 
bladder  with  dust  particles  that  adhere  to  unclean  instruments. 

In  1879,  IN'eisser  announced  the  discovery  of  the  gonococcus,  a  microorgan- 
ism which  has  since  then  been  found  as  the  constant  cause  of  blennorrhagic  in- 
fection. Then  followed  rapidly  the  discoveries  of  the  several  important  specific 
germs:  The  tubercle  bacillus  by  Robert  Koch,  in  1882;  the  staphylococcus,  the 
chief  germ  of  suppuration,  by  Rosenbach,  in  1884;  and  the  colon  bacillus — 
so  often  found  in  cystitis,  pyelitis,  etc.— by  Escherich,  in  1885.  These  dis- 
coveries changed  many  of  our  previous  etiologic  concepts  and  created  entirely 
new  therapeutic  view  points — antisepsis  and  asepsis.  The  development  of  a 
plate-culture  method  by  Koch  had  a  great  deal  to  do  with  the  later  and  more 
accurate  studies  on  the  bacteriology  of  cystitis,  pyelitis,  etc. 

The  amalgamation  of  the  diseases  of  the  urinary  tract  into  the  modern 
specialty  has  taken  place  through  the  combination  of  the  work  of  numerous 
internists,  surgeons,  pathologists  and  bacteriologists  at  different  times  and  in 
different  ways. 

A  knowledge  of  diseases  of  the  urethra  and  bladder  and  their  treatment  has 
existed  since  the  earliest  writings,  and  of  diseases  of  the  kidney  since  the  days 
of  Hippocrates.  The  diseases  of  the  kidney,  however,  were  not  considered  in 
conunon  with  those  of  the  bladder  and  the  urethra,  but  were  rather  in  the 
hands  of  internists  and  general  surgeons. 

Bright  was  the  first  thoroughly  to  consider  diseases  of  the  kidney  frcnn 
tlie  point  of  view  of  an  internist,  and  Raver  and  Simon  as  surgeons;  while 
Civiale,  Thompson,  Mercier,  Guyon,  Maisonneuve,  Ricord,  and  others  were 
working  on  the  bladder  and  urethra  in  both  a  medical  and  surgical  way. 

Tlie  laboratory  men  were  principally  engaged  in  the  work  of  urinary  anal- 
ysis until  Pasteur's  discovery  of  bacteria  and  microbic  infection,  followed  later 
by  the  discovery  of  the  gonococcus,  the  tubercle  bacillus  and  streptococcus, 
colon  bacillus  and  others  of  the  important  forms  of  infection. 


6  HISTORY   OF   DISEASES    OF   THE   URINARY   TRACT 

Cystoscopy  in  the  hands  of  Kitze  and  Brenner  was  perhaps  the  final  step 
of  an  amalgamation;  for  it  allowed  the  surgeon  who  had  examined  and  passed 
through  the  urethra  to  see  with  certainty  the  condition  of  the  bladder  wall, 
and  to  diag-nosticatc  in  many  cases  between  bladder  and  kidney  hematuria  and 
pyuria,  and  in  case  of  renal  origin  to  see  from  which  side  the  pathological  urine 
had  come. 

The  further  investigations  of  the  microbic  causes  of  disease  showed  that 
the  same  germs  that  give  rise  to  infectious  bladder  diseases  were  also  the  cause 
of  suppurative  renal  disease:  also  that  practically  the  same  diseases  existed  in 
both  organs ;  that  is,  tumors,  tuberculosis,  stone  and  suppurative  inflammations. 
Furthermore,  it  Avas  then  learned  that  in  cases  of  disease  of  the  urethra,  pros- 
tate and  bladder,  the  infection  may  pass  to  the  kidney  directly  up  the  ure- 
ters, or  by  the  blood  current  or  the  lymphatic  channels. 

The  catheterizing  cystoscopes  then  came  as  another  step  in  the  relation 
between  the  two  kidneys.  In  urinary  cases,  the  analysis  could  tell  us  of  disease 
of  the  bladder,  or  kidney,  or  both.  The  cystoscope  could  show  us,  in  a  bladder 
case,  the  degTee  of  disease  in  this  organ ;  while  in  a  kidney  case,  the  urine, 
withdrawn  by  the  ureteral  catheters,  could  tell  us  which  of  the  kidneys  ex- 
creted the  urine  that  gave  the  pathological  appearances  to  the  general  specimen. 
By  this  means,  direct  connection  between  the  bladder  and  the  kidney  was  es- 
tablished, and  the  study  of  the  urinary  tract  from  the  bladder  up  was  consid- 
ered just  as  important,  if  not  more  so,  than  from  the  bladder  down.  Conse- 
quently, the  direct  reason  for  including  the  entire  urinary  tract  from  the 
capsule  of  the  kidney  to  the  external  urinary  meatus  in  both  sexes  can  be  better 
understood. 

Having  considered  some  of  the  principal  direct  steps  taken  in  modern  urol- 
ogy toward  its  advancement  and  development  into  the  present  specialty,  we 
must  consider  a  few  imi^ortant  factors  in  general  and  special  surgery  that  have 
an  important  bearing  on  the  subject. 

The  acceptance  of  the  fact  that  germs  are  the  cause  of  surgical  infections 
led  to  the  consideration  of  the  best  way  to  be  rid  of  them  in  surgical  work; 
that  is,  the  study  of  antisepsis  and  asepsis. 

In  1859,  Lemaire  found  that  carbolic  acid  was  the  active  constituent  of 
coal  tar  and  advocated  it  as  the  best  antiseptic.  It  w^as  thought  that  fermenta- 
tion and  putrefaction  were  due  to  the  access  to  the  wounds  of  particles  from 
the  air  that  could  be  destroyed  by  boiling,  heat  and  chemical  agencies.  Among 
the  latter  the  best  agents  were  carbolic  acid  and  bichlorid  of  mercury,  iu  which 
wounds  could  be  Avashed  and  dressings  soaked. 

The  title  "  antiseptic  method  "  was  given  by  Lister  to  a  form  of  wound 
treatment  founded  on  certain  definite  principles  and  commenced  by  him  in 
1865.  His  studies  were  founded  on  the  results  of  Pasteur's  researches  on 
spontaneous  generation,  which  served  as  a  guide  in  systematizing  his  investiga- 


MODEKN   UROLOGY  7 

tion.  "Working  on  the  liypotliesis  that  the  particles  of  dust-borne  germs  en- 
t('r('<]  the  wounds  at  the  time  of  operation,  he  devised  the  carbolic  spray  as  a 
uicnns  of  rendering-  aiitis('])tic  the  operative  field  in  surgical  operations.  Asep- 
sis then  succeeded  antise^jsis,  as  it  became  apparent  that  it  is  better  to  exclude 
germs  by  having  everything  connected  with  the  operation  sterile,  than  to  have 
germs  present  at  the  time  of  operation  and  tlien  try  to  render  them  inert  by 
the  use  of  strong  solutions.  The  sterilization  of  instruments,  dressings,  gowns, 
etc.,  beforehand,  and  the  wearing  of  rubber  gloves,  proved  more  simple  and 
effective  than  the  more  cumbersome  methods  of  trying  to  sterilize  after  the 
operation  had  begun.  For  the  technique  of  asepsis  we  are  much  indebted  to 
another  English  surgeon,  Lawson  Tait. 

Anesthesia  was  another  great  discovery  for  urinary  surgery.  In  the  years 
1844—47,  the  three  chief  methods  were  discovered  in  rapid  succession  and 
at  once  began  to  exert  an  important  influence  upon  the  development  of  painless 
major  urological  operations.  The  discovery  of  nitrous  oxid  gas  as  an  anes- 
thetic by  Wells  gave  us  an  invaluable  aid  for  brief  operations  and  for  examina- 
tions that  require  perfect  relaxation.  The  discoveiy  of  ether  anesthesia  by 
Morton  in  1846,  and  of  chloroform  anesthesia  by  Simpson  in  1847,  gave  us 
the  most  useful  means  of  rendering  patients  unconscious  that  have  yet  been 
discovered.  Ethyl  chlorid  and  cocain,  as  brought  out  by  Koler,  are  of  great 
value  as  local  anesthetics,  and  the  great  majority  of  urological  operations  can 
be  performed  imder  the  influence  of  the  latter. 

In  1895,  Conrad  Roentgen  discovered  the  X-ray,  the  perfection  of  which 
has  brought  to  the  urologist  another  valuable  means  of  diagnosis  in  suspected 
cases  of  stone  in  the  kidney,  the  ureter  and  bladder. 

Laboratory  experiments  through  the  inoculation  of  small  animals,  have  also 
been  of  great  service  to  us  in  determining  the  presence  or  absence  of  tubercu- 
losis in  disease  of  the  kidneys. 

A  few  years  ago,  the  determination  of  the  relative  efficiency  of  both  kid- 
neys, and  especially  of  each  kidney  separately  by  various  methods,  was  consid- 
ered as  one  of  the  important  diagnostic  and  prognostic  criteria  by  surgeons  and 
urologists  in  the  study  of  renal  diseases.  The  first  of  these  methods  employed 
to  test  the  functional  capacity  of  the  kidney  was  cryoscopy,  which  consisted  of 
freezing  the  urine.  This  was  introduced  in  1897  by  Koranyo  of  Budapest, 
but  has  been  little  used  in  this  country.  The  methylene  blue  test,  popular  with 
the  French  School,  came  next,  the  function  of  the  kidney  depending  upon  the 
early  or  late  appearance  in  the  urine  of  the  blue  or  chromogen  color  after  its 
injection  into  the  body.  The  phloridzin  test  was  advocated  by  Casper  and 
Richter  in  1900  and  was  the  favorite  method  of  the  German  School,  but  re- 
quired more  care  on  account  of  the  frequent  necessity  of  testing  the  urine  for 
sugar. 

It  is  difficult  at  the  present  time  to  see  along  what  lines  the  progress  in 


HISTORY    OF    DISEASES    OF    THE    URINARY    TRACT 


urology  will  extend.  The  steps  in  diagnosis  at  present  seem  to  be  qnite  com- 
plete, and  I  think  that  progress  will  probal^ly  be  along  the  lines  of  improved 
technique.  At  present,  what  is  most  needed  is  better  cooperation  between  the 
patient  and  the  surgeon  in  the  study  of  the  cases,  and  the  continuation  of  medi- 
cal treatment  and  careful  observation  before  resorting  to  operation,  except  in 
urgent  cases. 


CHAPTEK    II 
THE   ANATOMY  OF   THE   URINARY  AND   GENITO-URINARY  TRACT 

The  urinary  tract  in  both  sexes  is  arranged  in  a  series  which  begins  at  the 
kidneys  and  ends  at  the  external  nrinary  meatus.  The  various  parts  are  the 
kidney,  ureter,  bhidder  and  urethra.  The  kidneys  and  ureters  are  the  same 
in  both  sexes,  while  the  bladder  is  practically  the  same,  differing  only  in  re- 
gard to  its  external  relations.  It  will  thus  be  seen  that  the  urethra  is  the  part 
Avhich  differs  the  most  in  the  two  sexes.  In  women  it  is  short  and  entirely  in- 
dependent of  the  genital  tract  in  its  functions  and  in  its  relations  until  it 
reaches  the  external  meatus  in  the  sinus  uro-genitalis.  In  men,  from  the  open- 
ing of  the  common  ejaculatory  ducts  to  the  external  meatus,  the  genital  and 
urinary  canals  form  a  single  passage.  In  both  the  male  and  the  female  the 
urinary  organs  meet  the  genital  organs  at  the  sinus  uro-genitalis,  which  is 
found  in  the  prostatic  portion  of  the  urethra  in  men  and  in  the  vestibule  in 
Avomen.  At  this  point  in  the  male  the  urinary  tract  communicates  with  the 
ejaculatory  duct,  the  vesiculffi  seminales,  the  vasa  deferentia  and  the  testes; 
while  in  the  female  it  communicates  at  the  sinus  with  the  clitoris,  the  vulva, 
the  vagina,  the  uterus,  tubes  and  ovaries.  In  men  the  combined  relations  and 
functions  of  the  urinary  and  genital  tracts  in  the  urethra,  where  they  are  in 
common,  has  given  rise  to  the  expression  genito-urinary  tract  in  their  combined 
consideration. 

In  women,  on  the  other  hand,  except  in  foetal  life,  the  genito-urinary 
organs  are  divided  into  two  distinct  tracts,  the  genital  and  the  urinary.  These 
are  separated  from  each  other  throughout  their  entire  course,  and  although 
they  are  in  close  contact  with  each  other,  they  are  never  in  connnon  in  a  nor- 
mal condition ;  for  which  reason  they  are  not  spoken  of  as  the  genito-urinary 
tract. 

In  the  female  the  genital  and  urinary  organs  bear  a  delinite  relation  Id 
each  other,  the  urinary  being  in  front  of  the  genital  except  where  the  ureter 
passes  behind  the  broad  ligament. 

In  the  male,  the  urinary  tract  is  also  placed  anteriorly  as  far  as  the 
urethra,  but  from  the  internal  to  the  external  meatus  the  urinary  tract  is  sur- 
rounded by  j)arts  of  the  genital  tract — namely,  the  prostate,  the  corpus  spon- 
giosum, and  corpora  cavernosa — the  urethra  being  the  common  canal  for  the 
discharges  from  each. 


10     ANATOMY   OF   THE   URINAEY   AND   GENITO-UKINARY   TRACT 

Tliu  fulluwiiig  illii.stratiuii.s  will  give  an  idea  of  the  relation  of  the  genital 
and  urinary  tracts  to  each  other  when  removed  from  the  body : 


Fig.  1. — Anterior  View  of  the  Opened  Genito- 
urinary Tract  in  the  Male. 

pe,  the  pelvis  of  the  kidney. 

cor,  the  cortex,  the  part  between  the  cortex 

and  the  pelvis  being  the  medullary  portion. 
pyT,  pjTamid. 
ca,  the  calices. 
m.r,  the  medullary  rays. 
V,  the  ureters. 
B,  the  bladder. 
o.u,  the  ureteral  openings. 
i.u.m,  the  internal  urinary  meatus. 
o.e.d,  the  openings  of  the  ejaculatory  ducts  in 

the  prostatic  urethra. 
g.u.s,  the  genito-urinary  sinus. 
v.m,  the  veru  niontanum. 
b.u,  the  bulbous  urethra. 

d.c,  openings  of  the  ducts  of  Cowper's  glands. 
c.c,  corpus  cavernosum. 
c.s,  corpus  spongiosum. 
u,  urethra. 
/,  fossa  na\'icularis. 
e.u,7n,  external  urinary  meatus. 


Fig.  2. — Posterior  View    of   the    Genito-uri- 
nary Tract  in  the  Male. 
K,  kidney. 
pe,  peh-is. 
U,  ureters. 
B,  bladder. 
V,  vas  deferens. 
a,  ampulla. 
s.v,  seminal  vesicles. 
P,  prostate, 
c,  Cowper's  glands. 
T,  testicles. 
E,  epididymis. 
b.u,  bulb  of  urethra, 
c.s,  corpus  spongiosum. 
c.c,  corpus  cavernosum. 
G,  glans  penis. 


ANATOMY   OF    THE   URINARY   AND    GENITO-URINARY   TRACT      U 


I'lg'.  1  gives  (lie  niitcrior  view  of  the  genito-urinary  tract  in  the  male, 
and  Fig.  2  the  ]X)sterior.  In  Fig.  1  it  can  be  seen  how  the  nrine  excreted 
into  the  tubules  of  the  kidney  is  carried  down  through  the  calices,  the  renal 
pelvis  and  the  ureter  into  a  reservoir,  the  bladder,  where  it  accumulates  and 
from  which  point  it  enters  the  urethra  through  which  it  is  discharged  from  the 
body.  In  examining  the  first  part  of  the  urethra  as  it  passes  through  the  pros- 
tatic gland,  we  see  the  openings  of  the  ejaculatory  ducts  that  bring  the  secre- 
tions of  the  testes  and  seminal  vessels  into  the  urethra ;  also  the  openings  of  the 
prostatic  ducts  that  discharge  the  prostatic  fluid ;  while  lower  down  the  bulbous 
pcn-tion  will  be  seen  the  mouth  of  the  ducts  of  Cowper's  glands,  that  are  the 
last  to  contribute  to  the  formation  of  the  combined  fluid  known  as  semen  at 
the  time  of  its  ejaculation. 

In  Fig.  2  it  can  be  seen  how  the  spermatozoa  formed  in  the  testes  are 
carried  up  through  the  epididymis  and  vas  deferens  to  the  seminal  vesicles 
where  they  are  stored  and  from  which  point,  mixed  with  the  secretion  of  the 
vesicles,  prostate  and  Cowper's  glands,  they  are  discharged  from  the  urethra, 
as  has  already  been  shown  in  Fig.  1. 


Fig.  3. — Posterior  View  of  the  Relations  of  the  Genital  and  Urinary 
Organs  in  the  Male. 


1,  ureters. 

2,  vasa  deferentia. 

S,  right  seminal  vesicle  laid  open. 

4,  right  vas  deferens  laid  open. 

5,  prostate. 

6',  left  seminal  vesicle. 


7,  bladder. 

A,  outer  muscular  lai'er  of  liladder. 

B,  middle  muscular  layer  of  bladder. 

C,  inner  muscular  layer  of  bladder. 

D,  mucous  membrane  of  bladder. 


Fig.  3  is  a  view  of  the  posterior  aspect  of  the  bladder  prostate,  seminal 
vesicles,  ureters  and  vasa  deferentia.  The  right  vesicle  and  vas  have  been 
laid  open. 


12     ANATOMY    OF    TTTE   TRTNAKY   AND    GENITO-URINARY    TRACT 

Fig.  4  rc])rosents  an  interior  view  of  the  genito-iirinarv  ti-aet  in  the 
female-  tlic  kichicv  and  ureter  cii  riglit  side  are  split,  and  lhe  liUuhlcr  and 
urethra  below. 

Fig.  5  represents  a  posterior  view.  The  tubes,  uterus  and  vagina  are 
split.  Here  the  genital  tract  is  seen  to  be  behind  the  urinary,  excepting  where 
the  ureters  pass  behind  the  adnexa. 


Fig.  4. — Interior  View  of  the  Genito-urinart       Fig.  5. — Posterior  View    of   the    Genito-uri- 
Tract  in  the  Female.  nary  Tract  in  the  Female. 


Fig.  6  shows  the  side  view  of  the  kidney,  ureter  and  bladder  in  an  an- 
terior posterior  section  as  it  is  found  in  either  man  or  -woman.  If  this  is 
placed  aboA'e  either  the  male  or  the  female  urethra  chart  in  such  a  way  that  the 
urethral  opening  of  the  bladder  is  placed  at  the  beginning  of  the  urethral  canal, 
it  will  be  seen  that  the  Idadder  answers  for  either  sex  as  well  as  the  kidneys 
and  ureters. 

Fig.  7  represents  a  central  anterior  posterior  vertical  section  through  that 


ANATOMY    OF    THE    URINARY   AND    GENITO-URINARY    TRACT      13 


1  ■'■  \ 


Fig.  6. — Upper  and  Middle  Portions  of  the 
Urinary  Tract,  the  Kidney,  Ureter  and 
Bladder  of  Either  Sex  on  Sagittal  Sec- 
tion. 

S,  supra  renal  capsule. 

K,  kidney. 

p,  papillae. 

pr,  pyramids. 

c,  cortex. 

h,  hilum. 

pe,  pelvis. 

U,  ureter. 

B,  bladder. 

a,  apex. 
n,  neck. 

b,  base. 

CM,  cystic  orifices  of  ureter. 


Fig.  7. — Lower  Urinary  Tract  in  the  ]\L\le 
on  Sagittal  Section,  and  also  the  Internal 
and  External  Genital  Organs. 

V,  vas  deferens. 
S.V.,  seminal  vesicle. 

a,  ampulla. 

e.d,  ejaculatory  duct. 
E,  epidid.vmis. 
g.77i,  globus  major. 
g.min,   globus   minor. 

b,  body  of  the  epididymis. 
T,  testicle. 

P,  prostate. 

T.L.,  triangular  ligament. 

C,  Cowper's  gland. 

U,   urethra. 

p.u,  prostatic  urethra. 

b.u,  bulb  of  urethra. 

f.n,  fossa  navicularis. 

c.c,  corpus  cavernosum. 

C.S.,  corpus  spongiosum. 

gl,  glans  penis. 

cor,  corona. 

p,  prepuce. 

m,  meatus. 


14     ANATOMY   OF   TTTE   URINARY   AND   GENITO-IJRINARY   TRACT 


V. 


part  of  the  g-eni to-urinary  apparatus  of  the  male  that  is  in  common,  namely, 
the  penis,  prostate  and  urethra;  besides  which   it  shows  the  male  adnexa  on 

one  side,  that  is,  the  seminal  vesicles,  vas 
-.;';'=«.-..,      ■'■}  deferens,  epididymis  and  testis. 

/''  ^,:      \"y  If  Fig.   6   was   placed  on  Fig.   7   in 

/      Y'^T'  1  such  a  way  that  the  opening  of  the  blad- 

1       \"'    X'  der  was  to  fit  that  of  the  urethra,    and 

i     iij     ,.v    ^  t^6  seminal  vesicles  and  the  vas  deferens 

\     A/'""'  ]\  j  with    their    ampullae    were    properly    ad- 

justed, they  would  he  seen  to  lie  on  the 
back  of  the  bladder  as  in  Fig.  2. 

Fig.  8  depicts  an  anterior  posterior 
vertical  section  through  the  central  part  of 
the  female  genitals,  namely,  the  vesti- 
bule, clitoris,  vulva,  vagina  and  uterus. 
There  is  also  a  similar  section  through 
the  urethra  in  the  same  line.  The  Fal- 
lopian tube  and  the  ovary  are  also  sho^^^l, 
although  somewhat  out  of  position.  The 
place  for  a  dilated  bladder  corresponding 
in  size  with  that  of  Fig.  6  is  indicated 
by  dotted  lines.  If  Fig.  6  was  placed 
over  Fig.  8  in  such  a  Avay  that  the  blad- 
der would  fit  in  the  space  indicated  by 
the  dotted  lines,  it  would  be  seen  that  the 
uterus  would  lie  in  a  plane  posterior 
to  the  bladder,  and  that  the  tubes  and 
ovaries,  in  case  the  bladder  were  empty 
or  but  moderately  distended,  would  also 
lie  in  a  j)Osterior  plane. 


Fig.  8. — Genital  Org.\ns  and  Lower  Uri- 
nary Tract  in  the  Female  on  Sagittal 
Section. 


F,  fallopian  tube. 

f.e,  fimbriated  extremity. 

O,  ovary. 

U,  uterus. 

C,  cervix. 

B,  bladder. 

ur,  left  ureter  passing  alongside  uterus. 

R,  rectum. 

A,  anus. 

S,  symphysis  pubis. 

V,  vagina. 

cl,  clitoris. 

Ve,  vestibule. 

e.u.o,  external  urethral  orifice. 

L.M,  labium  major. 

L.Min.,  labium  minor. 

I.V,  introitus  vaginae. 

P.B,  perineal  body. 


These  figures  show  the  great  similar- 
ity in  the  upper  three  quarters  of  the  uri- 
nary tract  in  the  two  sexes  and  also  how 
much  closer  related  the  lower  quarter  of 
the  urinary  tract  is  to  the  genital  in  the 
male  than  in  the  female. 

This  intimate  relation  in  the  male  has 
been  the  reason  why  the  troubles  of  the 
genital  tract  have  been  called  "  genito- 
urinary "  in  men,  instead  of  "  andro- 
logical,"  which  would  correspond  to  the 
term  ^'  evnecoloeical  "  in  women. 


LOCATION   OF   THE   GENITO-URINARY   TRACT 


15 


The  iTrogenital  sinus  is  the  point  where  the  urinary  tract  joins  the  genital 
and  is  differently  located  in  the  two  sexes. 

Fig.  9  shows  the  urogenital  sinus  in  tlie  male.  It  is  situated  in  the 
prostatic  urethra  at  the  point  wliere  the  ejaculatory  ducts  open  into  the  canal 

about  one  inch  below  the  vesical  open- 


ing. 


wmm 

Fig.  9. — Genito-tjrinary  Sinus  in  the  Male, 
THE  Prostate  having  been  Opened  Ante- 
riorly AND  its  Lateral  Lobes  Retracted. 
(Testut.) 

At  this  point,  the  posterior  urethra  is  seen  in 
direct  communication  with  the  bladder,  and  with 
the  ejaculatory  ducts. 

1,  the  bladder. 

2,  urethra. 
S,  prostate. 

4,  veru  montanum. 

5,  frenum  of  the  veru  rnontanum. 

6,  urethral  crest. 

7,  prostatic  utricle. 

8,  orifices  of  the  ejaculatory  ducts. 

9,  prostatic  fossette. 

10,  lateral  depressions  of  the  veru  monta- 
num. 


Fig.  10.- 


-GENITO-tlRINARY    SiNUS   IN  THE 

Female. 


The  labia  minora  of  the  external  genitals  are 
seen  to  be  retracted,  showing  the  urethral  meatus, 
the  termination  of  the  urinary  tract,  and  just  below 
and  behind  it  the  vaginal  opening,  the  termination 
of  the  genital  tract. 


Fig. 


10  shows  it  in  the  female. 
It  is  situated  in  the  vestibule  of  the 
vulva,  where  the  urethra  and  the 
vagina  open. 


LOCATION    OF   THE    GENITO-URINARY   TRACT 

The  genito-urinary  tract  in  its  whole  course  has  an  extensive  location,  being 
partly  within  the  body  cavity  and  partly  without.  The  inside  part  extends 
from  the  costal  diaphragm  to  the  pelvic  diaphragm  (levator  ani  muscle)  below, 
while  the  outside  part  is  a  continuation  of  the  part  within  through  the  pelvic 
diaphragm  and  the  perineum,  to  end  in  the  external  meatus  in  the  male  and 
the  vestibule  in  the  female.  The  bony  framework  wliich  incloses  it  may  be 
said  to  consist  of  tlie  two  lower  ribs,  the  last  dorsal  and  the  lumbar  vertebra^,  and 
the  bones  entering  into  the  formation  of  the  pelvis.  These  are  bound  together 
by  ligaments,  especially  important  in  assisting  to  make  a  smooth,  pelvic  cav- 
ity out  of  an  irregular  bony  framework.      (See  Figs.  11  and  12.) 


16 


ANATO^rY    OF    TTTE    T'RTXAKY    AND    GEXITO-T'KIXARY    TRACT 


Fig.  11.— Anterior  View  of  the  Bony  Skeleton  of  the   Part  of  the  Body  in  Which  the 

Urin.\ry  Tract  is  Lodged. 


1 ,  anterior  common  ligament. 

£,  ilio-lumbar  ligament. 

3,  greater  sacro-sciatic  ligament. 


4,  lesser  sacro-sciatic  ligament. 

5,  obturator  foramen  and  membrane. 

6,  anterior  pubic  ligament. 


LOCATION    OF    TTTE    GEXTTO-URINARY   TRACT 


17 


l)()t]i  kidneys  and   the  upper  five  and  one  half  inches  of  tlu;  nrctcr   are 
Avitliin  llic  abdominal  cavity.      The  bladder,   seminal  vesicles,   the  hjwer  four 


Fia.  12. — Posterior  View  of  the  Bony  Framework  Enclosing  the  Urinary  Tract. 


1,  posterior  ilio-lumbar  ligament. 

2,  posterior  sacro-iliac  ligament. 


3,  lesser  sacro-sciatic  ligament. 

4,  greater  sacro-sciatic  ligament. 


and  one  half  inches  of  the  ureter,  the  prostate  gland,  and  part  of  the  vas  defer- 
ens arc  ^vithin  the  pelvic  cavity ;  while  the   penis,   testicles   and   part  of  the 


18     ANATOMY   OF   THE   URINARY   AND   GENITO-URINARY   TRACT 


Fig.  13.-SPACE  Occupied  by  the  Urinary  Tract  after  It  has  been  Lined  with  Its  Muscular 

Layer. 


1,  diaphragm. 

2,  inferior  vena  cava. 

3,  right  cms  of  diaphragm. 

4,  pectineus. 
6,  esophagus. 

6,  aorta. 

7,  left  cms  of  diaphragm. 

8,  quadratus  lumborum.  • 

9,  transversalis  fascia. 


10,  psoas  par^a^s. 

11,  iliacus. 

12,  psoas  magnus. 

13,  pyriformis. 
H,  coccygeus. 

15,  obturator  externus. 

16,  obturator  membrane. 

17,  obturator  internus. 


tttf;  pelytr 


19 


uretlirn  arc  outside  the  bod)'  cavity.  Tlic  kidneys  are  on  tlie  posterior  abdom- 
inal \vall  on  cither  side  on  the  last  dorsal  and  npper  three  lumbar  vertebra;. 
They  are  behind  the  peritoneum,  and  rest  behind  on  the  twelfth  rib,  crurse  of 
the  dia])hrai!,-m,  psoas  and  qnadratns  lumljornm  muscles  (Fig.  13).  The  ab- 
dominal portion  of  the  ureter  is  also  behind  the  peritoneum,  lying  npon  the 
psoas  and  running  downward  and  inward  as  far  as  the  brim  of  the  pelvis. 

The  intrapelvic  and  extrapelvic  portion  of  the  tract  is  so  intimately  re- 
lated to  the  various  structures  in  the  pelvic  cavity  and  perineum,  that,  in  order 
to  give  an  adequate  idea  of  their  location  and  relations,  a  brief  description  of 
the  joelvis  and  perineum  as  a  whole  must  be  given. 


THE   PELVIS 

The  pelvis  consists  of  a  surrounding  framework  of  bones  and  ligaments, 
the  inner  surface  of  the  bones  being  covered,  for  the  most  part,  by  muscle,  while 
a  sheet  of  muscle  arising  from  either  side  of  the  bony  wall  meets  in  the  middle 

1 


7  8  9 

Fig.  14. — The  Ligaments  Helping  to  Form  the  Pelvic  Floor  on  the  Right  and  on  the  Left,  the 
First  Layer  of  the  Muscles  Above  Covering  Them  and  the  Spaces  About  Them. 

7,  obturator  membrane. 


1,  anterior  common  ligament. 

3,  ilio-lumbar  ligament. 

S,  anterior  sacro-iliac  ligament. 

4,  greater  sacro-seiatic  ligament. 

5,  lesser  sacro-sciatic  ligament. 

6,  Y  ligament  of  Bigelow. 


8,  levator  ani. 

9,  obturator  internus. 

10,  pyriformis. 

11,  coccygeus. 


20     AXATOMV    OF    THE    URINARY    AND    (JENITO-URIXARY    TRACT 

lino,  to  close  the  space  below.  I'lie  iiinscles  are  covered  with  fascia,  constitiit- 
iiiii'  the  various  layers  described  as  pelvic  fascia.  Tliis  has  attachments  to  the 
prostate,  bladder,  vagina,  vesiciilic  seniinales  and  rectum,  and  forms  folds 
Avhicli  are  descril^ed  as  ligaments  of  these  organs.  The  whole  cavity  so  formed 
is  lined  by  a  complete  layer  of  peritonenm. 

The  bony  wall  consists  of  the  sacrum  behind  and  the  os  innominatum  on 
either  side,  meeting  in  front  at  the  symphysis  pubis.  The  ligaments  and  struc- 
tures "which  complete  the  framework  of  the  pelvis  are  the  sciatic  ligaments 
which  extend  over  the  sciatic  notch,  the  obturator  membrane  closing  the  ob- 
turator foramen,  and  the  triangular  ligament  wliich  bridges  across  the  space 
between  the  rami  of  the  ischium  and  pubes.  These  cover  the  irregular  open- 
ings in  the  bony  framework,  and  transform  the  lower  part  of  the  interior  into 
a  cylindrical  cavity  witb  more  or  less  complete  walls,  as  already  mentioned. 
The  muscular  structures  which  pad  the  inner  surface  of  this  framework  are 
the  pyriformis  and  obturator  internus.  They  cover  the  inner  surface  of  the 
bones  on  their  lateral  and  posterior  aspects,  and  obliterate  the  irregularities  of 
the  bony  wall,  thus  rendering  the  interior  a  comfortable  location  for  delicate 
organs. 

The  space  inclosed  by  these  various  structures  is  known  as  the  jielvic  cav- 
ity, and  may  be  likened  to  the  short  segment  of  a  liollow  cylinder,  deeper  be- 
hind than  in  front.  It  is  closed  in  below  by  the  levator  ani  and  coccygeus 
muscles,  which  are  known  as  the  pelvic  diaphragm,  but  the  coccyx  and  trian- 
gular ligaments  must  also  be  looked  upon  as  forming  part  of  the  true  floor  of 
the  space. 

Levator  Ani. — This  arises  from  the  back  part  of  the  pubic  bone  from  a 
line  of  fascia  (white  line.  Figs.  15-16)  extending  from  the  back  part  of  the 
pubes  and  from  the  inner  surface  of  the  ischial  spine.  The  anterior  fibers 
extend  do-wnward  and  inward  by  the  side  of  the  prostate,  meeting  those  of  the 
opposite  side.  The  intermediate  fibers  slope  downward  and  inward  and  sup- 
port the  rectum  and  bladder.  At  the  junction  of  the  rectum  and  anal  canal, 
they  form  a  collar  round  the  gut,  wliich  extends  downward  on  its  lateral  walls 
as  far  as  the  external  sphincter.  The  posterior  fibers  are  inserted  into  the  ano- 
coccygeal raphe  and  the  sides  of  the  coccyx  (Fig.  15).  In  the  female,  that 
portion  of  fibers  which  surrounds  the  prostate  in  the  male  are  attached  on 
either  side  to  the  vaginal  wall.  The  nerve  supply  for  this  muscle  comes  from 
the  fourth  and  fifth  sacral,  some  branches  of  the  same  nerves  going  to  the 
coccygeus. 

Coccyg"eus  Muscle. — This  is  a  small  fan-shaped  muscle  which  arises  from 
the  spine  of  the  ischium,  extending  backward  and  inward  to  be  attached  to 
the  sides  and  anterior  surface  of  the  coccyx.  The  levator  ani  and  coccygeus 
thus  form  one  continuous  sheet  of  muscle,  which  make,  as  it  were,  a  bed  and 
support  for  the  viscera    (Fig.    16).      They   are  both   the  remains   of  the  tail 


THE   PELVIS 


21 


iiinscles.     In  quaflnipeds  the  various  components  of  tlie  levator  ani  arise  from 
the  hi'iin  of  ilie  pelvis,   and  are  inserted   into  the  coccyx  or  caudal   vertebra*. 
/ 


y  10  11  l:i  IS  14  15 

Fig.  15. — View  of  the  Right  Side  of  the  Pelvic  Cavity  as  Seen  aftek  a  Sagittal  Section. 
The  sacrum  is  seen  above  and  the  pubis  below,  while  between  are  the  muscles  and  fascias  going  to 
make  up  the  pelvic  walls  and  floor.     The  urethral  orifice  is  seen  just  behind  the  pubis  and  behind  this 
the  stump  of  the  rectum;  extending  from  the  coccyx  to  the  pubic  bone  the  levator  is  seen. 


1,  cut  surface  of  the  sacrum. 

2,  pyriformis. 

3,  ilio-pectineal  line. 

4,  obturator  internus. 

5,  obturator  foramen. 

6,  urethral  opening. 

7,  bulbo-cavernosus  muscle. 

8,  corpus  spongiosum. 

.9,  deep  layer  of  triangular  ligament. 
10,  superficial  layer  of  triangular  ligament. 


lU  Cowper's  glands. 

12,  transversus  perinei  muscle. 

13,  sphincter  ani  externus. 

14,  rectum. 

15,  levator  ani  cut  through. 

16,  gluteus  maximus. 

17,  pyriformis. 

18,  coccygeus. 

19,  levator  ani. 


With  the  assumption  of  the  upright  posture,  the  muscles  become  modified  to 
form  one  sheet,  their  origin  sinks  downward,  while  they  acquire  their  various 


22     ANATOMY   OF    THE   URINAKY   AND    GENITO-TJRINARY   TRACT 


insertions  and  increase  in  strength,  to  support  the  viscera  wliicli  tend  to  sink 
downward  from  gravity,  the  effect  of  gravity  being  markedly  increased  in  tlie 
upright  position.     In  man,  traces  of  the  former  attachment  of  these  muscles 

1 


Fig.   16. — The  Pelvic  Floor  Looking  in  from  Above. 
The  pubis  is  seen  in  front,  the  vertebra  behind  and  the  ilium  and  pubes  on  cither  side. 

1,  symphysis.  6,  obturator  internus. 

2,  prostatic  urethra.  7,  levator  ani  muscle. 

3,  seminal  vesicles.  5,  coccygeus. 

4,  rectum.  9,  pyriformis. 

6,  cut  surface  of  Uiac  bone.  10,  prostate  gland. 

can  often  be  found.  The  coccygeus  and  small  sciatic  ligaments  arc  the  rcin-c- 
sentatives  of  the  ischio  coccygeus,  the  lateral  flexors  of  the  tail  in  lower  ani- 
mals (Keith's  "Embryology"). 

Pelvic  Fascia. — This  can  be  best  understood  by  considering  the  develo])- 
ment  of  fascia  in  general.  This  structure  is  never  developed  in  sheets,  as  is  so 
commonly  described,  but  is  merely  the  portion  of  mesoblast  left  over  after 
structures  have  formed  within  it.  Thus  w^e  see  that  fascia  must  form  a  con- 
tinuous attenuated  spongcAvork,  in  which  the  interstices  are  filled  with  struc- 
tures which  have  become  differentiated.  We  can  now  understand  the  intimate 
relations  of  the  fascia  covering  the  levator  and  its  connections  with  the  pros- 
tate gland,  bladder,  the  vesicular  seminalis,  uterus,  vagina  and  rectum.  With 
the  above  considerations  in  mind,  we  see  that  the  parietal  layer  of  pelvic  fascia, 
so  called,  is  merely  the  internal  sheath  of  the  pyriformis  and  obturator  in- 
ternus muscles.  The  visceral  layer,  laterally  and  behind,  is  the  upper  portion 
of  the  sheath  of  the  levator  ani,  while  in  front  the  visceral  layer  is  really  the 


THE   PELVIS 


23 


posterior  layer  of  tlie  triangular  ligament,  which  is  itself  the  posterior  portion 
of  the  sheath  of  the  compressor  urethra.  The  fibrous  covering  of  the  prostate, 
bladder,  vesicul<T3  seminales,  vagina,  uterus  and  rectum  are  thus  continuous 
with  these  muscle  sheaths,  and  form  the  fascia  described  as  the  vesical,  recto- 
vesical, and  rectal  layers  of  pelvic  fascia  (Fig.  17).  The  internal  and  ex- 
ternal capsules  of  the  jn'ostate  are  so  called  because  a  partial  line  of  cleavage 
.has  been  made  by  blood  vessels  developing  in  the  mesoblastic  spongework.     The 


17  9 
Fig.  17. — View  of  the  Internal  Genitals  and  the  Pelvic  Fascia  in  the  jNIale  as  Seen  from 
Behind,  after  the  Rectum  has  been  Separated  and  Pulled  Down. 

1,  bladder.  11,  white  line  fascia. 

2,  vas  deferens.  12,  obturator  fascia. 

3,  ureter.  13,  anal  fascia. 

4,  seminal  vesicle.  1^,  recto-vesical  fascia  covering  levator  ani 
6,  obturator  internus  muscle.  muscle. 

6,  prostate.  IS,  recto-vesical  fascia  split  and  reflected  from 

7,  Alcock's  canal.  bladder,  prostate  and  seminal  vesicles. 

8,  levator  ani  muscle.  16,  recto-vesical    fascia    forming    capsule    of 

9,  rectum  drawn  down.  prostate. 

10,  pelvic  fascia.  17,  recto-vesical  fascia  reflected  from  rectum. 


anal  fascia  covering  the  perineal  surface  of  the  levator  ani  is  merely  the  sheath 
of  the  under  surface  of  the  muscle. 

Peritoneum. — Internal  to  the  fascial  lining  of  the  pelvic  cavity  is  a  com- 
plete covering  of  peritoneum.     This  lines  the  sides  of  the  pelvis,  being  contin- 


24      ANATOMY    OF    THE    URINARY   AND    GENITO-URINAKY    TRACT 

nous  \\illi  tlu!  ])erit(nieal  lining-  of  the  abdominal  cavity,  and  is  reflected  on  to 
the  floor  of  tlic  space,  covering  more  or  less  of  the  pelvic  viscera  (Fig.  18). 
The  peritoneal  coverings  can  be  best  understood  by  imagining  the  peritoneum 
as  extending  down  into  the  pelvic  cavity  as  a  closed  sac,  and  the  viscera  as 
having  been  pushed  up  from  below,  evaginating  portions  of  the  bottom  of  the 


Fig.  18.— Extraperitoneal  Sagittal  Section  of  the  Body  to  the  Left  of  the  Median  Line. 

The  ureter  is  seen  extending  down  until  it  enters  the  bladder.  The  vas  deferens  with  the  peritoneum 
above  and  extraperitoneal  portion  of  the  bladder  below  is  seen  running  horizontally  toward  the  ureter 
and  passing  in  front  of  it  to  become  an  ejaculatory  duct.  The  prostate  is  seen  below  the  bladder  and 
between  its  base  and  the  ureter  on  the  posterior  wall  of  the  bladder  the  stump  of  the  seminal  vesicle  is 
seen. 

sac  and  not  having  been  pushed  np  far  enough  to  get  comj^lete  coverings.  Thus 
the  bladder  is  covered  on  its  superior  surface  as  far  as  the  apex,  on  the  upper 
part  of  the  lateral  surface,  and  covering  over  the  basal  surface  far  enough  to 
cover  one  third  of  the  vesiculse  seminales.  In  front,  from  the  apex  of  the 
bladder,  it  is  reflected  on  to  the  anterior  abdominal  wall.  Behind  from  the 
base  of  the  bladder  it  passes  backward  on  to  the  rectum  in  the  male,  forming 
the  recto-vesical  pouch.  In  the  female,  it  covers  the  uterus  alcove,  in  front  and 
behind,  the  two  layers  meeting  laterally  to  form  the  broad  ligament.  From 
the  uterus  it  is  reflected  on  to  the  rectum,  forming  the  utero-sacral  pouch  or 
pouch  of  Douglas.     It  covers  the  middle  third  of  the  rectum  on  the  anterior 


THE    PERINEUM  25 

surface,  cxtciKliiia,'  liackward  and  upward  over  the  sides  to  the  upper  third, 
whicli  is  covered  in  front  and  on  the  side,  tlieuce  l)lendiiio'  Avith  the  parietal 
layer. 

The  Llood  vessels  in  the  pelvis  run  beneatli  the  ])eritoneum.  The  larger 
trunks,  internal  iliac  and  its  lateral  branches,  are  found  on  the  side  wall  of  the 
pelvis,  superficial  to  the  fascia,  while  the  visceral  branches  run  inward  to  their 
distribution  between  the  peritoneum  and  fascia.  The  sacral  nerves,  with  the 
exception  of  the  obturator,  are  fonnd  beneath  the  fascia,  the  obturator  is  super- 
ficial, running  beneath  the  peritoneum,  and  leaves  the  pelvis  through  a  special 
opening  in  the  parietal  fascia  at  the  upper  part  of  the  obturator  foramen. 

THE   PERINEUM 

The  perineum  is  a  lozenge-shaped  space  between  the  pelvic  floor  above  and 
the  cutaneous  surface  below."  It  is  bounded  on  the  sides  by  the  rami  of  the 
pubes  and  ischium,  the  ischial  tuberosity,  and  the  great  sciatic  ligament,  in 
front  by  the  symphysis  pubis  and  behind  by  the  coccyx.  The  superficial  fascia 
covering  this  space  presents  certain  characteristics  of  surgical  importance  (Fig. 
10).  It  is  fatty  behind,  muscular  in  front,  where  it  extends  over  the  scrotum, 
the  muscular  fibers  being  known  as  the  dartos,  and  accounts  for  the  rugosities 
in  the  skin  of  the  scrotum.  The  middle  portion  is  divided  into  two  layers,  the 
superficial  layer,  continuous  with  the  superficial  fascia  of  surrounding  parts, 
and  a  deep  layer  known  as  the  fascia  of  Colles.  This  is  attached  on  either 
side  to  the  jDubic  arch  and  behind  winds  round  the  posterior  border  of  the  trans- 
versus  perinei  muscle  to  form  a  firm  attachment  to  the  anterior  layer  of  the 
triangular  ligament.  In  front  it  is  continuous  with  the  fascia  of  Scarpa  on  the 
anterior  abdominal  wall.  This  fascial  connection  is  very  important,  as  it  de- 
termines the  direction  of  extravasated  urine  in  cases  of  rupture  of  the  urethra 
anterior  to  the  triangular  ligament  The  perineal  space  is  arbitrarily  divided 
into  two  portions  by  a  line  extending  transversely  across  the  space  between  the 
two  ischial  tuberosities.  This  line  passes  just  in  front  of  the  rectum,  and 
forms  the  urogenital  triangle  in  front  and  the  rectal  triangle  behind. 

The  Rectal  Triangle. — This  contains  the  rectum  with  its  sphincter  mus- 
cles, and  on  either  side  of  it  is  the  ischio-rectal  fossa.  The  latter  is  a  pyram- 
idal-shaped space  filled  with  fat  which  is  derived  from  the  superficial  fascia. 
Crossing  the  space  from  without  inward,  are  the  inferior  hemorrhoidal  vessels 
and  nerves,  which  come  oft"  from  the  internal  pudic  artery  and  nerve  as  they  lie 
on  the  inner  surface  of  the  ischium,  in  the  fascial  sheath  known  as  Alcock's 
canal.  The  fourth  sacral  nerve  is  found  in  the  posterior  part  of  the  space, 
while  the  two  superficial  perineal  nerves  arise  from  the  internal  pudic  and 
run  a  short  distance  in  the  anterior  part  of  the  space  before  they  pierce  the 
triangular  ligament  and  enter  the  urogenital  triangle. 


26     ANATO:\rY    OF    TTTE    URINAHY   AND    GENTTO-URINARY    TRACT 

The  Urogenital  Triangle. — The  two  layers  of  the  superficial  fascia  having 
])een  described,  we  come  next  to  the  various  muscles  beneath  this,  which  meet 
in  the  central  jiart  of  the  triangle.      This  is  called  the  central  point  of  tlic 


Fig.  19. — Muscular  Layer  of  the  Perineum  on  the  Right  Side  after  the  Re.moval  of  the  Super- 
ficial Fascia. 

On  the  left  side  the  muscular  layer  has  been  removed,  sho-ndng  the  corpus  spongiosum  with  its  bulb 
and  the  roots  of  the  corpora  cavernosa,  whereas  below  the  superficial  layer  of  the  deep  fascia  (the  tri- 
angular ligament)  is  seen. 


1,  bulbo-cavernosus  (accelerator  urinse)  muscle. 
S,  ischio-cavernosus  or  erector  penis  muscle. 

3,  ischio-cavernosus  or  erector  penis  muscle. 

4,  transversus  perinei. 

5,  anus. 

6,  sphincter  ani  externus. 

7,  corpus  spongiosum. 

8,  corpus  cavernosum. 

9,  CoUes'  fascia  reflected. 


10,  adductor  muscle  of  tliigh. 

11,  cut  surface  corpus  cavernosum  muscle. 
13,  anterior  or  superficial  layer  of  triangular 

ligament. 

13,  tuber  ischii. 

14,  obturator  internus. 

15,  levator  ani. 

16,  gluteus  maximus. 

17,  COCCJTC. 


perinemxL,  or  perineal  bod}'.  It  is  merely  a  fibrous  septum  situated  a  little  in 
front  of  the  anus,  into  which  are  attached  the  anterior  portion  of  the  sphincter 
ani,  the  bulbo-cavernosus,  the  anterior  fibers  of  the  levator  ani,  and  the  trans- 
versus perinei  muscles. 


THE   PERINEUM 


f  f 


27 


Si'iriNCTER  Ani. — The  spliincter  ani  is  a  band  of  lunsdc  fibers  extendinj^ 
from  the  coccyx  behind  to  the  perineal  body  in  front.  It  forms  a  niuscuhir 
colhir  round  the  lower  part  of  the  anal  canal. 

Tbansvkksu.s  Pekinki. — These  fibers  extend  from  tlie  ascendino-  ramus  of 
the  isehiuin  near  the  tu])erosity  horizontally  inward  to  be  attached  to  the  cen- 
tral point  of  the  perineum. 


Tig.  20. — Anterior  Perineal  Triangle  after  the  Removal  of  the  Muscles,  the  Corpus  SroxGE 

OSUM    AND    THE    CORPORA    CAVERNOSA    COVERING    It. 

The  urethra  is  seen  near  the  middle  of  the  triangle. 

1,  corpus  spongiosum.  8,  sphincter  ani  externus. 

2,  corpus  cavernosum.  9,  levator  ani. 

3,  dorsal  vein  to  penis.  10,  gluteus  maximus. 

4,  dorsal  artery  to  penis.  11,  urethra. 

5,  adductor  muscle  of  thigh.  13,  tuber  ischii. 
6',  superficial  layer  triangular  ligament.  13,  anus. 

7,  artery,  vein  and  nerve  to  bulb.  14<  urethra. 


BuLBo-CAVEEisrosus. — The  biilbo-cavernosiis  is  a  muscular  sheet  covering 
the  bulb  and  extending  on  to  the  corpus  spongiosum.  It  arises  from  the  central 
point  of  the  perineum,  and  from  a  tendinous  septum  formed  by  the  union  of 


28  I  ANATOMY    OF    TIIK    rKlXAlfV    AXD    (I  KXlTO-l' Ul  XAltY    TRAC^T 

the  two  muscles.  Some  of  flic.  filxTS  com])lctc'ly  encircle  the  bulb,  meeting 
those  of  the  o]iposite  side;  olhci-s  extend  forward  jind  enclose  the  corpora  cav- 
ernosa; while  the  posterior  iihers  are  attaclied  directly  to  the  triangular 
ligament. 

Iscjiio-c'AVERNOSus  jMusci.Ks. — These  muscles  arise  on  eitlier  side  frcjm  the 
inner  surface  of  the  ischial  tuberosity.     They  extend  forward,  comj)letely  cov- 


F      E    0 


L  ^ 


Fij.  21. — The  Outer  Layer  of  the  Triangular  Ligament  on  the  Right  Side,  and  on  the  Left 
THE  Space  Between  the  Two  Layers  of  the  Ligament. 


D,  dorsal  nerve  of  penis. 

E,  dorsal  artery  of  penis. 

F,  dorsal  vein  of  penis. 
U,  urethral  opening. 

T,  anterior  layer  of  triangular  ligament. 
L,  posterior  layer  of  triangular  ligament. 
M,  compressor  urethrae  muscle. 

G,  Cowper's  gland. 

K,  duct  of  Cowper's  gland. 
A,  internal  pudic  nerve. 


B,  internal  pudic  artery. 

C,  internal  pudic  vein. 

1,  vein  of  corpus  cavernosum. 
£,  artery  of  corpus  cavernosum. 
3,  nerve  of  corpus  cavernosum. 
A'",  nerve  of  bulb. 
Y,  artery  of  bulb. 
Z,  vein  of  bulb. 
P,  pubic  rami. 


ering  the  crura  of  the  joenis  and  are  attached  to  the  corpora  cavernosa.  These 
various  muscles  divide  the  urogenital  triangle  into  two  lesser  perineal  triangles, 
the  boundaries  of  which  are  the  bulbo-cavernosus  muscles  on  either  side  and 
the  transversus  perinei  muscles  behind  (Fig.  19).  At  the  bottom  of  this 
jDerineal  triangle  is  found  a  dense  fibrous  structure  on  which  these  muscles  seem 
to  rest.  This  fibrous  structure  is  the  anterior  layer  of  the  triangular  ligament 
(Fig.  20).  As  we  liave  seen  before,  this  is  on  the  same  plane  with  the  bony 
wall  of  the  pelvis,  and  is  attached  firmly  to  the  rami  of  the  pubes  and  ischium, 


THE   PERINEUM 


20 


while  behind  it  receiv^es  a  firm  attachment  to  tlic  fascia  of  Colics  (Fig.  20). 
It  is  perforated  at  its  posterior  part  by  the  urethra,  and  a  short  distance  on 
either  side  of  this  the  artery  of  the  bulb  comes  through.  About  half  an  incli  in 
front  of  the  urethral  openinii',  it  is  ])ierccd  l)y  the  internal  pudic  artery  and 
dorsal  nerve  of  the  penis,  while  the  superficial  perineal  vessels  and  nerves  enter 


3  4  5  6  7 

Fig.   22. — The   Male  Perineum  after  the   Removal  of  the   Deep  Layer  of  the  Triangul.'\.r 

Ligament. 

Here  we  see  the  other  side  of  the  levator  ani  muscle  to  that  shown  in  Fig.   IG. 

1,  urethra.  6,  gluteus  maximus. 

2,  triangular  ligament.  7,  great  sacro-sciatic  ligament. 
5,  obturator  intcrnus  muscle.                                          8,  dorsal  vein  of  penis. 

Ji,  levator  ani  muscle.  5,  recto-vesical  fascia. 

5,  sphincter  ani  externus.  '  10,  capsule  of  prostate  gland. 

the  urogenital  triangle  by  piercing  its  base  (Fig.  21).  The  deep  or  superior 
layer  of  the  triangular  ligament,  as  we  have  seen,  is  merely  a  portion  of  the 
pelvic  fascia,  but  between  the  so-called  superior  and  the  anterior  or  triangular 
ligament  proper  is  a  definite  space.     The  structures  found  in  this  interval  are 


30     ANATOMY   OF    THE    T^RINARY   AXD    OENTTO-URTNARY   TRACT 


the  nretlira,  surrouiided  by  tlio  comprossor  nretlira^  muscles,  Cowper's  glands, 
the  internal  piidic  artery  and  dorsal  nerve  of  the  penis,  the  artery  to  the  bulb, 
and  the  dorsal  vein  of  the  penis  which  has  entered  this  space  by  passing  baek- 


FiG.  23. — The  Perineum  in  the  Female  after  the  Removal  of  the  Labia. 


On  the  right  beneath  the  deep  layer  of  the  superficial 
left  side,  after  removing  the  muscular  layer,  the  corpus 
layer  of  the  triangular  ligament  are  seen. 

1,  clitoris. 

2,  CoUes'  fascia  reflected. 

5,  bulb  of  vagina. 

4,  corpus  cavernosum. 

6,  opening  of  vagina. 
6',  adductor  muscle. 

7,  cavernosum  muscle — ischio-cavernosus. 

8,  superficial  layer  of  triangular  ligament. 
.9,  tuber  ischii. 

10,  levator  ani. 


fascia  the  muscular  layer  is  seen,  and  on  the 
cavernosum,  vaginal  bulb  and  the  superficial 

11,  obturator  internus. 

12,  gluteus  maximus. 

13,  coccyx. 

14,  urethral  opening. 

15,  ischio-bulbosus  (sphincter  vaginae). 

16,  vagina. 

17,  corpus  cavernosus  muscle. 

18,  transversus  perinei. 

19,  anus. 

20,  sphincter  ani  externus. 


ward  through  a  small  opening  between  the  anterior  triangular  ligament  and  the 
subpubic  ligament  (Fig.  21). 

Compressor  Urethr>t:. — This  arises  from  the  inner  side  of  the  ischio- 
pubic  rami  on  either  side,  the  two  muscles  meeting  in  the  mid  line  and  inclos- 
ing the  urethra.     The  larger  body  of  the  muscle  is  inserted  behind  the  urethra. 


THE   PERINEUM 


31 


Just  below  this  muscle  is  a  group  of  muscle  fibers  arising  from  the  ramus  of 
the  ischium  and  continuous  with  the  compressory  urethra  at  its  insertion;  this 
is  called  the  transversus  perinei  profundus.  Sometimes  muscular  fibers  (com- 
pressor venffi  dorsalis)  from  the  anterior  portion  of  the  bulbo-cavernosus  mus- 
cle pass  obliquely  outward  and  forward,  inclosing  the  entire  circumference  of 
the  root  of  the  penis  and  the  dorsal  vessels. 

Internal  Pudic  Artery. — The  internal  pudic  artery  arises  from  the  an- 
terior division  of  the  internal  iliac,  passing  out  of  the  pelvis  through  the  small 


Fig.  24. — Anterior  I^ayer  of  the  Triangular  Ligament  in  the  Female,  after  the  Removal  of 
THE  External  Genitals,  the  Superficial  Fascia  and  Muscles. 

The  urinary  and  vaginal  passages  are  seen.  It  corresponds  to  Fig.  20  in  the  male. 

1,  urethral  opening.  6,  levator  ani. 

2,  vagina.  7,  sphincter  ani  externus. 

3,  tuber  ischii.  S,  gluteus  maximus. 

4,  adductor  muscles  of  thigh.  9,  coccyx. 
6,  superficial  layer  of  triangular  ligament. 


sciatic  notch ;  it  crosses  over  the  spine  of  the  ischium  and  enters  the  perineal 
space,  running  along  the  ischial  tuberosity  in  the  fascial  sheath  known  as  Al- 
cock's  canal.  This  is  situated  about  an  inch  and  a  half  from  the  lower  border  of 
the  ischial  tuberosity.  It  ascends  to  the  inner  surface  of  the  ramus  of  the  pubes, 
and  about  one  half  inch  below  the  symphysis  pubis  pierces  the  triangular  liga- 


32     ANATOMY    OF    THE   URINARY   AND    GENITO-URINARY    TRACT 

ment  and  is  continued  onward  to  the  dorsal  artery.  Its  branches  are  inferior 
hemorrhoidal,  superficial  and  transverse  perineal,  artery  to  the  bulb,  and  artery 
to  the  corpus  cavernosus. 

IxTEKXAL  PuDic  Xekve. — Tliis  arises  from  the  sacral  plexus  and  follows 
the  same  course  as  the  artery,  the  nerve  being  situated  usually  above.  As  it  passes 
over  the  ischium,  it  divides  into  two  branches,  the  perineal,  and  dorsal  nerves  of 
the  penis.  The  perineal  nerve  breaks  up  to  supply  the  small  perineal  muscles 
previously  described,  and  the  two  superficial  perineal  nerves  supply  the  skin  over 
the  part  as  far  forward  as  the  scrotum.     The  dorsal  nerve  of  the  penis  is  contin- 


5  6  7  8 

Fig.  25. — The  Deep  Layer  of  Muscles  Forming  the  Floor  of  the  Pelvis  in  the  Female  from 

THE  Outside. 


The  urethral  and  vaginal  openings  are  seen. 

1,  urethra. 

2,  adductors. 

3,  tuberosity  of  iscliium. 
4-,  obturator  internus. 

5,  gluteus  maximus. 


It  resembles  Fig.  22  in  the  male. 

6,  coccjrx. 

7,  sphincter  ani. 

8,  levator  ani. 

9,  great  sacro-sciatic  ligament. 


ued  onward  with  the  internal  pudic  artery  and  dorsal  artery  of  the  penis.     Fig. 
22  shows  a  deep  dissection  of  perineum  after  removal  of  triangular  ligament. 

Female  Perineum. — In  the  female  the  perineum  is  divided  into  urogenital 
and  rectal  triangles,  as  in  the  male.     The  rectal  triangle  does  not  differ  in  any 


THE   KIDNEYS 


33 


way  from  that  found  in  the  male.  In  the  urogenital  triangle  the  vagina  makes 
some  alteration  in  the  relation  of  the  parts.  The  ischio-bulbosus  muscle  is 
found  in  two  separate  parts  covering  over  the  bulb  as  it  lies  at  the  sides  of  the 
vagina  (Fig.  23).  The  vagina  also  makes  a  cleft  in  the  triangular  ligament, 
which  structure  in  the  female  is  of  less  density  than  in  the  male  (Fig.  24). 
Fig.  25  shows  a  deep  dissection  of  female  perineum  after  removal  of  tri- 


ano'ular  ligament. 


THE  KIDNEYS 


The  kidneys  are  the  glands  which  secrete  the  urine.     They  are  situated  on 
the  jjosterior  abdominal  wall  behind  the  peritoneum,  between  the  upper  border 


Fig.  26. — The  Posterior  Surfaces  of  the  Kidneys  and  their  ReLu\tions  to  the  Ribs. 

(Recamier.) 

of  the- twelfth  dorsal  and  middle  of  tlie  third  lumbar  vcrtebriTp  (Fig.  2G).  The 
right  kidney  extends  to  the  lower  border  of  the  eleventh  rib;  the  left  is  placed 
somewhat  higher,  and  its  upper  pole  may  rest  on  the  eleventh  rib.  Below,  they 
are  both  separated  by  a  short  interval  from  the  crest  of  the  ileum.  The  kidney 
is  a  bean-shaped  body,  four  and  one  half  inches  (11.2  cm.)  in  length,  two  and 
one  half  inches  (6.2  cm.)  in  breadth,  and  one  and  one  half  inches  (3.7  cm.)  in 
thickness.     Its  weight  is  about  four  and  one  half  ounces. 


34     ANATOMY    OF    THE    URINARY    AND    GENITO-T^RIXARY    TRACT 

Relations  of  the  Kidney. — Tlie  kidney  has  an  anterior  or  visceral  surface, 
a  posteridr  or  niuscuhir  surface,  an  internal  border  or  hilus,  and  an  external 
border.  The  upper  and  lower  ends  of  the  kidney  are  called  respectively  tlie 
upper  and  lower  poles. 

The  anterior  surface  of  the  kidney  looks  forward  and  slightly  outward,  and 
is  jDartly  covered  by  peritoneum.     On  the  right  side,  it  is  in  relation  above  with 


27. — The  Relation  of  the  Kidxets  axd  Suprarenal  Capsitles  to  the  Tissues  ix 


Front  of  Them. 


caval  area. 

gastric  area  (peritoneal). 

hepatic  area  (nonperitoneal). 

gastric  area  of  spleen. 

duodenal  area  (nonperitoneal). 

splenic  artery. 

hepatic  area  (peritoneal). 

pancreatic  area  (nonperitoneal). 


(Morris.) 

9,  duodenal  area  (nonperitoneal). 

10,  coUc  area  of  spleen. 

11,  mesocolic  area. 

12,  colic  area  (nonperitoneal). 
14,  mesocolic  area. 

16,  ureter. 
18,  aorta. 
20,  vena  cava. 


the  right  suprarenal  body,  which  extends  farther  down  the  anterior  surface  on 
the  right  than  on  the  left  (Fig.  27).  The  outer  three  fourths  of  the  upper 
half  of  the  kidney  lies  behind  the  liver  and  is  covered  by  peritoneum.  The 
outer  three  fourths  of  the  lower  half,  just  below  the  hepatic  area,  is  behind  the 
ascending  colon  and  the  mesocolic  area  and  is  not  covered  by  peritoneum  be- 
neath the  colon.  The  inner  quarter  of  the  organ  is  behind  the  duodenum,  and 
is  nonperitoneal  as  is  its  colic  area.  The  small  area  on  the  internal  aspect  of 
the  anterior  surface  of  the  upper  third  of  the  kidney  is  in  relation  with  the 
inferior  vena  cava. 

The  anterior  surface  of  the  left  kidney  is  in  relation  above,  for  a  small 
space,  with  the  left  suprarenal  (Fig.  27).  The  upper  fifth  of  the  anterior  sur- 
face lies  behind  the  stomach,  and  is  covered  by  peritoneum.  The  middle  two 
fifths  is  behind  the  pancreas,  nonperitoneal.  The  lower  two  fifths  lies  behind 
the  colon  and  mesocolon,  the  latter  being  peritoneal.     A  narrow  strip  of  the 


THE   KIDNEYS 


35 


anterior  surface  in  its  outer  part  is  in  apposition  with  tlie  renal  surface  of  the 
s})]e('n,  and  connected  to  this  organ  hy  the  lieno-renal  liuaiiient. 

The  posterior  surface  on  both  sides  in  its  upper  third  rests  upon  the 
diaphragm,  the  twelfth  rib  crossing  behind  this  (Fig.  28).  Between  the  dia- 
pliragni  and  the  lower  ribs,  the  pleura  extends  for  a  considerable  distance  be- 
hjntl  llio  kidney.  The  inner  third  of  the  lower  two  thirds  lies  upon  the  psoas, 
the  middle  third  on  the  quadratus  luniborum,  and  the  outer  third  rests  upon 
the  tendon  of  the  transversalis.  The  last  dorsal  ilio-hypogastric  and  ileo-in- 
guinal  nerves  pass  in  a  direction  downward  and  outward  behind  tlie  kidney 
on  both  sides.  The  external  arcuate  ligament  and  transverse  processes  of  the 
upj^er  three  lumbar  vertebra^  lie 
immediately  behind  the  muscular 
bed  of  the  kidney. 

OUTLIWE    OF   12Xi!    RIB 


Pelvis 


Ureter  -  - 


PapillcE 


Urirn'f- 


Calyx 


FiG.  28. — The  Relation  of  the  Kidneys 
TO  THE  Tissues  behind  Them.    (Morris.) 

1,  transverse  processes   of   the  first  and  sec- 

ond lumbar  vertebrae. 

2,  line  indicating  outer  border  of  quadratus 

lumlDorum. 


Fig.  29. — Median  Vertical   Section  of  the  Right 
Kidney.     (Poirier.) 
The  renal  artery  and  vein,   the  interior  of  the  pel- 
vis, calices,  the  ureter,  the  papillae  and  pj-ramids  are 
seen. 


The  inner  horder  of  the  kidney  in  its  middle  part  consists  of  an  anterior 
and  posterior  lip,  forming  a  fissure  Avhich  is  known  as  the  hilum.  In  a  space 
between  these  lips,  which  extends  into  the  kidney  substance  for  a  short  dis- 
tance, is  the  renal  sinus,  and  here  the  blood  vessels  and  ureter  enter  the  kidney 
(Fig.  29).     These  vascular  structures  are  known  as  the  ikmHcIc. 

The  relations  from  before  backward  are  vein,  artery,  ureter.  From  above 
downward  the  relation  is  artery,  vein,  ureter.  The  upper  pole  of  the  kidney 
supports  the  suprarenal  body  posteriorly.     It  is  in  relation  v;ith  the  inner  sur- 


36     ANATOMY   OF   THE   URINARY   AND    GENITO-URINARY   TRACT 


—13 


face  of  the  twelfth  rih,  or  on  the  left  side  may  lie  in  front  of  the  eleventh.     The 
diaphragm  and  pleura  intervene  between  the  kidney  and  the  bone.     The  lower 

pole  reaches  abont  two  inches  from  the  iliac 
crest  and  is  situated  farther  from  the  median 
line  than  the  upper  pole. 

The  external  harder  of  the  kidney  is 
formed  by  the  meeting  of  the  anterior  and 
posterior  surfaces,  and  rests  upon  the  tendon 
of  the  transversalis.  The  kidney  is  closely  in- 
vested by  a  fibrous  capsule,  which,  winding 
round  the  lips  of  the  hilum,  lines  the  renal 
sinus  and  also  sends  prolongations  over  the 
vessels  and  ureter. 

The  Pelvis  of  the  Kidney. — This  arises 
from  the  kidney  sinus  by  a  series  of  small 
tubes,  eight  to  twelve  in  number,  called  calices, 
surrounding  one  or  more  papillae.  These  fuse 
into  one,  two  or  three  larger  ducts,  whicb  in 
turn  unite  to  form  the  pelvis.  This  cone- 
shaped  duct  extends  inward  and  downward, 
decreasing  rapidly  in  size  to  become  continu- 
ous with  the  upper  end  of  the  ureter  (Fig. 
29). 

Perirenal  Tissue. — When  the  kidney  de- 
velops, it  grows  out  as  an  evagination  from 
the  Wolffian  duct.  This  diverticulum  extends 
into  the  surrounding  mesoblastic  tissue,  a  por- 
tion of  which  becomes  differentiated  to  form 
the  kidney  cortex.  The  part  of  the  mesoblast 
that  remains  outside  tlie  cortex  forms  the  peri- 
renal tissue.  This  remaining  spongework  be- 
comes filled  with  fat  and  surrounds  the  kidney, 
being  thickest  above,  behind  and  externally. 
As  we  see  from  this  mode  of  formation,  no 
special  ligaments  are  developed  to  hold  the  kid- 
ney in  place,  although  by  special  dissection 
some  of  the  fibrous  tissue  may  be  described  as 
such. 

This    surrounding    tissue    above    is    car- 
ried   upward    to    the    diaphragm    (Fig.    30), 
internally  over  the   spinal  column    (Fig.    31)    to  the  opposite  kidney,   while 
below^  it  extends  on  the  posterior  abdominal  wall  as  far  as  the  iliac  fossa. 


Fig.  30. —  The  Renal  Fascia  after 
A  Sagittal  Incision  Through  the 
Kidney.     (Testut  and  Jacob.) 

1,  kidney  with  its  sinus. 

2,  suprarenal  capsule. 

3,  perirenal  fascia  in  front  of  kidney. 

4,  perirenal  fascia  behind  kidney. 
6,  common  insertion  of  its  two  leaves 

into  the  diaphragm. 

6,  fatty  capsule. 

7,  pararenal  fascia. 

8,  opening  below  the  two  layers  of 

perirenal  fascia. 

9,  diaphragm. 

10,  twelfth  rib. 

11,  quadratus  lumborum  muscle. 

12,  crest  of  ilium. 

13,  parietal  peritoneum. 

14,  adipose  and  cellular  tissue  in  the 

iliac  fossa. 


THE   KIDNEYS 


37 


Below  it  (Iocs  not  form  so  markedly  a  closed  sac  as  it  does  over  the  upper  part 
of  the  kidney.  This  is  due  to  the  fact  that  the  kidney  originates  below  and 
travels  upward  as  it  develops.  The  chief  agents  in  maintaining  the  kidney  in 
its  normal  position  are  the  intra-abdominal 
pressure,  the  attachments  to  the  various  vis- 
cera, and  to  some  extent  the  perirenal  tissue. 


Fui.  31. — The   Renal   Fascia  after 
cisioN  Through  the  Kidney 
A' A',  the  median  line. 

1,  the  kidney. 

2,  aorta. 
2',  inferior  vena  cava. 

3,  perirenal  fascia. 

4,  po.sterior  leaflet  of  perire- 

nal faseia. 

5,  anterior  leaflet  of  perire- 

nal fascia. 


Horizontal  In- 
(Testut.) 

6,  6,  fatty  capsule. 

7,  pararenal  fat. 

8,  parietal  peritoneum. 

9,  vertebra. 

10,  psoas  muscle  wit  hits  apo- 
neurosis. 

11,  quadratus  lumborum  with 
its  aponeurosis. 


Fig.    32. — Sagittal    Section    of    the 
Kidney.      (Henle.) 
u.t,  uriniferous  tubes. 
c.t,  cortex  with  pyramids  of  Ferrein. 
m,  pyramids  of  Malpighi. 
i,  column  of  Bertini. 
p,  papilla. 

c,  calyx  embracing  papiUa. 
m.r,  medullary  rays. 
P,  pelvis. 
u,  ureter. 
a.a,  artery. 


Structure. — The  kidney  on  section  shows  an  outer  cortical  layer  called  the 
cortex,  and  an  inner  called  the  medulla  (Fig.  32).  The  medulla  consists  of 
pyramidal  masses,  eight  to  twenty  in  number,  with  their  base  toward  the  cor- 
tex, called  pyramids  of  Malpighi.  Their  apices  form  small  prominences  (renal 
])apillie)  which  project  into  the  renal  calices,  and  contain  the  orifices  of  the 
kidney  tubules.  Between  the  pyramids  are  found  the  columns  of  Bertini ; 
these  are  processes  from  the  cortex  and  contain  blood  vessels,  lymphatics  and 
nerves. 

At  the  bases  of  the  j)yramids  in  the  cortex,  are  seen  the  medullary  rays 
which  are  made  up  of  the  cortical  portions  of  the  straight  collecting  tubules,  the 
descending  and  ascending  limb  of  Henle  and  blood  vessels.  The  areas  of  cortex 
between  these  raj's  are  known  as  the  labyrinth.  The  pyramids  of  Ferrein  are 
seen  at  the  perijihery  of  the  cortex  and  lie  external  to  the  medullary  rays  and 
labyrinth. 


38     ANATOMY    OF    THE    URINARY   AND    GENITO-URINARY    TRACT 


The  kidney  siihstauce  is  iiindc  ii]>  of  siiial]  fnl)ii]('s,  wliieli  consist  of  a  l)ase- 
ineiit  nienibranc   lined   with  epillieliiini   and   separated  one  from   the  other  by 

connective  tissue.      The  tubules 
■Ef'pEHENT  Vessel  begin   as  blind   dilated   extreni- 

~AFr£f^eNr  V  ^^^^^  "^  ^^'^  labyrinths  and 
form  what  is  called  the  cap- 
sule. This  is  surrounded  by 
looped  capillary  blood  vessels, 
which  in  turn  are  covered 
by  a  thin  reflected  layer  of 
the  capsule.  The  capillaries 
are  thus  inclosed  between  the 
two    layers    and    tlie    whole    is 


GIoMeyulus, 


CApsu/e^  of 


Fiu.  33. — Malpighian  Corpuscle. 


ur/f* 


WTW 


Fig.  34. — Scheme  of  the  Renal  Tubes  and  Blood  Vessels  (from  ^^■ilson:   modified  from  Klein). 

On  the  left  of  the  figure  the  arrangement  of  the  Ijlood  vessels  of  the  kidney  is  shown,  on  the  right  the 
course  of  the  uriniferous  tubules. 


v.s,  venae  stellatse  of  Verheyen. 

v.i,  interlobular  veins. 

■y.r,  vense  rectse. 

m.v,  veins  of  medullary  part. 

«.p,  veins  of  papillae. 

a.i,  interlobular  artery. 

g,  glomerulus. 

a.r,  arteriae  rectae. 

a.m,  arteries  of  medullary  part. 


A,  cortex. 

B,  boundary  zone. 

C,  papillary  zone  of  medulla. 
a.a' ,  superficial  and  deep  layers 

of  cortex,  free  of  glomeruli. 

1,  Malpighian  capsule. 

2,  neck. 

•S,  first  convoluted  tubule. 
4,  spiral  tubule  of  Schachowa. 


5,  descending    limb   of    looped 

tubule  of  Henle. 

6,  bend. 

7,  8,  9,  ascending  limb. 

10,  irregular  tubule. 

11,  second  convoluted  tubule. 

12,  junctional  tubule. 

13,  H,  collecting  tubule. 
15,  excretory  tubule. 


THE   KIDNEYS 


39 


called  a  ]\Ialpii;liian  corpusele  (Fig.  S-'Jj.  Tlic  first  part  of  tlie  tuUiilo  Icad- 
iiii;'  from  the  capsule  is  the  first  convoluted  tubule;  it  passes  through  the 
labyrinth  to  the  medullary  ray  and  becomes  the  spiral  tubule.  Thence  it  passes 
into  the  intermediate  zone,  then  straight  through  the  pyramid  toward  the  apex. 
This  part  is  known  as  the  descending  limb  of  Plenle's  loop.  Near  the  apex 
it  bends  around,  forming  the  loop  of  Ilenle,  and  passes  npward  through  the 
pyramids,  through  the  intermediate  zone  into  the  medullary  ray,  as  the  ascend- 
ing limb  of  Ilenle's  loop.  It  now  continues  its  course  to  the  labyrinth  as  the 
irregular  tubule,  becoming  more  uniform  within  the  labyrinth ;  this  portion 
is  known  as  the  second  convoluted  tubule.  -    2     1 

This  ends  in  the  jnnctional  tubnle  which, 
];)assing  into  the  medullary  ray,  joins 
the  collecting  tubule.  The  collecting  tu- 
bule is  made  up  of  several  renal  tubules 
and  pursues  a  straight  course  to  the  apex 
of  the  pyramid.  Here  several  unite  to 
form  one  excretory  duct,  which  opens 
at  the  renal  papillae  in  the  kidney  sinus 
(Fig.  34). 

Blood  Supply. — The  kidney  is  sup- 
plied with  blood  by  the  renal  artery.  The 
chief  function  of  this  artery,  however, 
is  not  to  nourish  the  gland  but  to  allow 
the  various  products  of  metabolism  in  the 
systemic  circulation  to  be  acted  upon  by 
the  kidney. 

The  Renal  Artery. — In  the  sinus, 
the  artery  subdivides  into  a  fan-shaped 
plexus,  as  seen  in  Fig.  29,  and  the  ter- 
minal branches  enter  the  projections  pro- 
duced by  the  columns  of  Bertini  (Fig. 
35).  On  entering  these,  at  their  cen- 
ters, the  arteries  at  once  bifurcate,  so 
that  each  division  skirts  the  boundary  of 
a  ])yrauiid.  Faeh  pyramid  is  supplied  with  four  or  five  arteries  which  travel 
along  its  surface  until  the  base  is  reached  (lobar  or  peripyramidal  arteries). 
At  the  bases,  they  give  transverse  arched  branches  which  anastomose  with 
similar  branches  from  other  lobar  arteries,  and  form  the  su]irapyramidal  arch 
or  plexus.  The  meshes  of  this  network  surround  the  base  of  a  ])vramid 
transversely  like  a  collar.  From  this  network  arise  a  nund)er  of  arteries 
directed  toward  the  fibrous  capsule,  usually  between  two  pyramids  of  Ferrein 
(Fig.  30). 


2.     i 

Fig.  35. — The  Renal  Artery  and  Its 
Branches.     (Testut.) 
Right  kidney.     Sagittal  section  seen  from 
the  front. 

1,  capsule. 

2,  pyramids  of  Malpighi. 

3,  3,  columns  of  Bertini. 

4,  renal  artery. 

5,  its  posterior  branch. 

G,  its    anterior   branch    bifurcating. 

7,  peripyramidal  arteries. 

8,  renal  pelvis. 
■9,  ureter. 


40     ANATOMY   OF    THE    URINARY   AND    GEN  I  TO-URINARY    TRACT 


These  arterioles,  known  as  the  interlobular  vessels,  end  in  the  capsule  in 
"  capsular  branches,"  some  of  which  perforate  into  the  perirenal  fat.  The  in- 
terlobular  vessels,   however,   give   off   lateral   branches   all    along  their   route 

through  the  parenchyma, 
which  end  in  the  afferent  ves- 
sels of  numerous  ]\lalpighian 
tufts. 

The  glomerular  capillaries 
are  twisted  around  each  other, 
forming  the  lobulated  tuft  de- 
scriljed  above,  and  end  in  an 
efferent  arterial  capillary. 

Leaving  the  glomeruli,  the 
efferent  capillaries  pass  toward 
the  convoluted  tubules  and 
the  pyramids  of  Ferrein,  and 
form  a  network  which  sur- 
rounds and  supplies  all  the 
cortical  tubules.  In  the  me- 
dulla, the  straight  tubules  are 
found  accompanied  by  parallel 
capillaries — the  arteria*  recta? 
— which  are  probably  also  de- 
rived from  the  efferent  capil- 
laries of  the  glomerulus.  The 
arterise  rectne  form  a  rectangu- 
lar network  about  the  papillary 
orifice  of  the  collecting  tubule. 
Abnormalities  of  the  Kidneys. —  (1)  Complete  absence  of  one  kidney. 

(2)  One  kidney  very  small  and  atrophied,  the  other  hypertrophicd  and 
very  large. 

(3)  Lobulation,  such  as  is  seen  in  the  foetus  and  in  some  of  the  lower 
animals. 

(4)  Horseshoe  kidney,  the  two  kidneys  being  fused  together  at  the  lower 
pole. 

(5)  Abnormal  position,  one  kidney,  usually  the  left,  luay  be  ])laeed  very 
low,  opposite  the  sacro-iliac  synchondrosis,  this  being  the  location  of  its  early 
origin, 

(6)  More  than  one  renal  artery  may  be  present,  or  the  main  artery  may 
break  \\-p  before  it  enters  the  sinus. 


Fig.  36. — Schematic  Drawing  Showing  the  Theory  of 
THE  Arrangement  of  the  Vascular  Arches  over  the 
Pyramids.     (Testut.) 

1,1,  two  Malpighian  pyramids. 
£,  sinus  of  the  kidney. 

3,  columns  of  Bertini. 

4,  arterial  arches. 

5,  venous  arches. 

6,  branches  of  the  renal  artery. 

7,  branches   of  the  renal  vein. 

8,  interlobular  arteries. 

9,  interlobular  veins. 

10,  direct   (straight)   veins. 


THE  UEETER 


41 


THE  URETER 

The  ureter  is  a  fibro-mnsciilar  canal,  wliich  conducts  the  urine  from  the  kid- 
ney to  the  bladder.  When  in  situ  it  measures  about  fifteen  inches  (37  cm.) 
(Fig.  37). 


Fiu.  37. — Showing  the  Relations  of  the  Ureter  to  the  Inferior  Pole  of  the  Kidney  and  to 
THE  Blood  Vessels  of  This  Region.     (Hartmann.) 

On  both  sides,  it  lies  on  the  psoas  muscle  behind  the  peritoneum  (Fig.  38), 
and  is  crossed  obliquely  by  ovarian  or  spermatic  vessels.  The  genito-crural 
nerve  passes  behind  it  on  both  sides,  in  a  direction  from  within  downward  and 
outward.  On  the  right  side,  the  duodenum  lies  in  front  of  its  commencement. 
Lower  down  it  is  crossed  by  the  ileo-colic  artery  and  the  root  of  the  mesentery. 
On  the  left  side,  the  left  colic  artery  and  the  mesentery  of  the  pelvic  colon  pass 
in  front. 


42     ANATOMY   OF   THE   URINARY   AND   GENITO-URINARY    TRACT 

Crossing  the  pelvic  brim  at  the  bifurcation  of  the  common  iliac  or  at  the 
commencement  of  the  external  iliac  (Fig.  39),  it  passes  down  from  the  side 
Avail  of  the  pelvis  in  a  curved  direction,  the  convexity  of  the  curve  being  back- 
ward. It  passes  over  the  obturator  nerve  and  artery  and  obliterated  hypogas- 
tric artery,  as  they  riui  forward  on  the  side  wall  of  the  pelvis.  At  the  spine 
of  the  ischium,  it  crosses  inward  over  the  floor  of  the  pelvis  and  is  crossed  In* 
the  vas  deferens  near  its  termination.  As  it  enters  the  bladder,  it  lies  in  front 
of  the  vesiculce  seminales  and  is  surrounded  by  veins  continuous  with  the 
vesical  and  prostatic  plexus.     As  they  enter  the  bladder,  the  two  ureters  are 


Fig.  38. — ^A  Sagittal  Section  of  the  Pelvis  to  the  Left  of  the  Median  Line.     (After  Hartmann.) 

On  the  right  the  peritoneum  is  seen  intact  with  the  ureter  outside  of  it,  whereas  on  the  left  the  extra 
peritoneal  tissue  and  the  common  iliac  branching  into  the  external  and  internal  iliac  branches  are  seen. 
If  the  two  sides  were  brought  together  the  ureter  would  occupy  the  space  at  the  bifurcation  of  the 
common  iliac. 


placed  about  two  inches  (5  cm.)  apart.  They  run  from  the  bladder  wall  in 
an  inward  direction  for  three  quarters  of  an  inch  (1.87  cm.)  (Fig.  40),  and 
open  on  the  internal  surface  by  two  valvular  slitlike  orifices  which  in  the  empty 
bladder  are  about  one  inch  (2.5  cm.)  apart.  In  the  female,  the  pelvic  portion 
of  the  ureter  has  somewhat  different  relations.  As  it  runs  down  on  the  side 
wall  of  the  pelvis,  it  produces  a  ridge  in  the  peritoneum,  Avhich  forms  the  pos- 
terior boundary  of  a  small  fossa  (fossa  ovarica)  in  which  the  ovary  lies.  The 
upper  and  anterior  boundary  of  this  fossa  are  formed  by  the  external  iliac.  It 
then  passes  inward  underneath  the  broad  ligament,  passing  over  the  vault  of 


THE ■ URETER 


43 


in      11       13  18  14 


19  20    21 

YiQ,  39._The  Relations  of  the  Ureter  to  the  Pelvic  Tissues.     (After  Duval.) 
The  ureter  is  seen  to  pass  just  below  the  bifurcation  of  the  common  iliac. 


1,  ascending  colon. 

2,  end  of  ileum  held  up. 

3,  appendix  held  up. 
Jf,  common  Uiac. 

5,  superior  hemorrhoidal. 
G,  right  sigmoidal. 

7,  middle   sigmoidal. 

8,  internal  iliac. 


9,  external  Uiac. 

10,  right  ureter. 

11,  vena  cava. 

12,  aorta. 

13,  inferior  mesenteric  artery. 


IJ^,  left  ureter. 

15,  psoas  muscle. 

16,  left  sigmoidal  artery. 

17,  internal  Uiac. 

18,  colon. 


19,  anterior  layer  of  pelvic  mesocolon. 

20,  posterior  layer  of  peritoneum. 

21 ,  posterior  layer  of  pelvic  mesocolon. 


f^UCOUS  CofiT. 

/^uscuIar  Coat 


Fig.  4f). — Ureter  Passing  through  the  Wall 
OF  the  Bladder  and  Opening  into  Its  Cavity. 


Ureter: 


44     ANATOMY    OF    THE    URINAKY   AND    GENITO-URINARY    TRACT 


the  lateral  fornix  of  the  vagina  about  a  quarter  of  an  inch  (0.6  em.)  from  the 
lateral  border  of  the  cervix  uteri.  Near  its  termination  it  is  crossed  by  the 
uterine  artery  (Fig.  41).  Its  course  within  the 
bladder  is  the  same  as  in  the  male. 

Structure. — The  wall  is  composed  of  an 
outer  librous  layer,  then  a  middle  muscular 
layer,  the  muscular  coat  being  in  three  strata. 


Ute.ru-vaginal  plexus 
Uterine  vein 

L. 

Posterior  uterine  vein 
Ureteral  artery  - 
Ureteral  artery 

Vesico-vaginal  plexus 
Anterior  uterine  vein       -•■-' 
Cervico-vaginal  artery 

Vaginal  artery 


_   Ureter 


Fig.  41. — Schematic  Drawing  of  the  Relations  of  the  Ure- 
ter TO  THE  Neck  of  the  Uterus  and  Its  Vessels.  (Poirier.) 
L.L,  is  a  line  drawn  just  below  the  uterine  isthmus.  The 
striations  below  this  represent  the  vaginal  wall.  The  outline  of 
the  cervix  uteri  is  indicated  in  this  area  by  a  dotted  line.  An 
arch  in  front  of  the  cervix  and  vagina  represents  the  outline  of 
the  bladder  wall  through  the  sides  of  which  the  ureters  are  seen 
to  extend.  On  the  right  side  of  the  cervix  about  the  ureter,  the 
uterine  and  vaginal  arteries  and  veins  are  seen.  The  uterine  artery 
and  vein  pass  in  front  of  the  ureter. 


The  middle  fibers  are  circular,  the  outer  and 
inner  longitudinal.  Inside  of  the  muscular 
coat  is  the  mucous  membrane,  the  epithelium 
of  which  is  the  same  as  that  found  in  the 
bladder. 

Caliber  of  the  Ureter. — The  caliber  of  the 
ureter  is  not  uniform  throughout  its  extent. 
At  its  junction  with  the  pelvis,  its  diameter 
is  about  3.2  mm.  From  this  point  on  it  gradu- 
ally dilates  until  it  reaches  a  diameter  of  8  mm. 
As  it  passes  from  the  abdomen  into  the  pelvis,  its  diaiiiotor  is  abdut  4  iiiiii. 
From  that  point  to  its  termination  there  is  a  slight  gradual  decrease  in 'its 
caliber  (Fig.  42). 

Variations. — The  ureter  is  sometimes  double  at  its  commencement;  some- 
times it  is  double  throughout  its  course.  In  rare  cases,  one  ureter  may  ojien 
into  the  vagina  or  urethra. 


Fig.  42. — Shape  of  the  Right  Ure- 
ter AFTER  It  has  been  INJECT- 
ED WITH  Tallow.      (Testut.) 

1,  pehas  of  kidney. 

2,  infundibulum. 
S,  narrowing. 

4,  wide  or  abdominal  portion. 

5,  bend  at  pelvic  brim. 

6,  narrowing  at  brim. 

7,  widening  in  pelvic  portion. 

8,  9,  external  iliac  artery  and  vein. 
10,  vesical  orifice. 


THE  BLADDER 


45 


THE  BLADDER 

The  bladder  is  a  muscular  pouch  which  acts  as  a  temporary  reservoir  for 
the  urine.  Its  capacity  varies  in  different  individuals,  but  an  average  is  about 
twelve  ounces.  It  is  situated  in  the  anterior  part  of  the  pelvic  cavity,  beliind 
tlio  symphysis  pubis  and  the  retro-pubic  pad  of  fat,  and  in  front  of  the  rectum, 
from  which,  in  the  male,  it  is  separated  by  the  vesiculse  seminales  and  the  ter- 
minal portion  of  the  vas  deferens.     In  the  female,  it  is  separated  from  the  rec- 


FiG.  43. — Bladder  But  Slightly  Dilated  on  Sagittal  Section,  Showing  Its  Apex 

AND  Base.     (Poirier.) 

1,  vas  deferens.  5,  seminal  vesicle. 

2,  Retzius  space.  6,  prostate. 

3,  plexus  of  Santorini.  7,  transverse  deep  perineal  muscle. 

4,  retro-vesical  fold.  8,  transverse  superficial  perineal  muscle. 

tum  by  the  uterus  and  upper  part  of  the  vagina  (Fig.  47).  It  presents  varying 
forms  and  relations  according  to  whether  it  is  distended  or  empty. 

Relations. — The  bladder  has  an  aj^ex  and  five  surfaces ;  they  are  a  superior 
or  abdominal,  a  postero-inferior  or  basal,  antero-inferior  or  pubic  and  two  lateral 
(Figs.  43  and  44). 

The.  apex  looks  upward  and  forward  and  is  connected  to  the  abdominal  wall 
by  a  fibro-muscular  cord,  the  urachus.  On  either  side  of  it  are  the  obliterated 
h^'pogastric  arteries  which  pass  upward  from  the  sides  of  the  bladder. 

TJie  superior  or  abdominal  surface  is  entirely  covered  by  peritoneum  and 
extends  antero-posteriorly  from  the  apex  to  the  base.  Laterally  it  is  separated 
from  the  sides  of  the  bladder  by  the  obliterated  hypogastric  arteries  (Fig.  45). 

The  antero-inferior  or  puhic  surface  (Figs.  46  and  47)  is  that  part  of  the 
bladder  in  relation  with  the  symphysis  pubis,  the  triangular  ligament,  internal 
obturator  muscles  and  the  anterior  portions  of  the  levator  ani.  It  looks  down- 
ward and  forward,  and  is  not  covered  by  peritoneum. 


40     ANATOMY    OF    THE    UUl.XAliV    AM)    OEXITO-rRINAKY    TRACT 

The  hose  or  fundus  (diagrammatic  view)  looks  do^\Tiward  and  backward 
(Fig.  48).  In  the  male,  it  is  in  relation  to  the  rectum,  from  which  it  is  sepa- 
rated by  a  reflection  of  the  recto-vesical  fascia.  In  the  female,  the  base  lies  in 
contact  with  the  ii])per  part  <»£  the  aiitci-jor  wall  <if  tlie  vagina  and  the  cervix 
of  the  uterus. 

The  lateral  surfaces  or  sides  (Fig.  48)  are  in  relation  to  the  levator  ani 
and  obturator  internus  muscles  with  their  fascial  coverings.      The  sides  are 


20         19         18  ' 
Fig.  44. — Vertical  Transverse  Section  of  Pelvis  just  in  Front  of  the  Internal  Meatus  Show- 
ing THE  Trigone  and  the  Urethral  Orifices.      (Poirier.) 


1,  neck  of  bladder. 

2,  ureteral  orifice. 

3,  bladder. 

4,  lateral  ligament. 

5,  obturator  fascia. 
6',  levator  ani  fascia. 

7,  obturator  intrenus  muscle. 

8,  levator  ani  muscle. 

9,  pelvic  layer  of  fa.scia. 

10,  lateral  prostatic  fascia  (capsule). 


11,  extension  of  ischio-rectal  fossa. 

12,  internal  pubic  artery. 

13,  deep  transverse  perinei  muscle. 

14,  ischio-pubic  ranius. 

15,  corpus  cavernosum. 

16,  ischio-cavernosus  muscle. 

17,  bulbo  cavernosus  artery. 
IS,  bulbo  cavernosus  muscle. 

19,  membranous  urethra. 

20,  bulb  of  the  urethra. 


crossed  obliquely  from  Lelo-w,  upward  and  forward,  by  the  obliterated  hypo- 
gastric artery.  Above  and  behind  tliis  cord,  the  bladder  is  covered  by  peri- 
toneum, while  below  and  in  front,  it  is  covered  by  recto-vesical  fascia. 

That  portion  of  the  bladder  immediately  around  the  internal  urethral 
orifice  is  called  the  ''  neck.''  In  the  male,  it  rests  upon  tlie  prostate  and 
connects  with  the  urethra  passing  through  it,  but  has  no  definite  anatomical 
limits. 


THE    BLADDER 


47 


The  Distended  Bladder. — ^Vllon  the  bladder  is  distended,  the  various  bor- 
ders and  surfaces  are  obliterated  so  that  the  bladder  assumes  an  oval  shape 
(Fig.  49).  The  superior  sur- 
face, upper  part  of  the  infra- 
lateral  and  ui)i)er  part  of  the 
basal  surfaces,  take  most  part  in 
the  distention,  and  the  lateral 
and  posterior  borders  are  oblit- 
erated. The  superior  surface, 
from  being  almost  a  flat  plane, 
assumes  varying  degrees  of  con- 
vexity until  it  comes  to  represent 
a  segment  of  a  sphere  (Fig,  49). 
The  peritoneal  reflection  from 
the  apex  is  carried  upward  with 
increasing  distention  nntil  it  may 
be  from  one  to  two  inches  (2^  to 
5  c.c.)  above  the  symphysis,  thus 
markedly  increasing  the  area  of 
the  prevesical  space,  or  space 
of  Eetzius.  Laterally,  the  peri- 
toneal reflection  from  the  side 
wall  of  the  pelvis  is  also  elevated. 
Behind,  its  alteration  in  position 


Fig.  45. — The  Peritoneal  Reflection  on  the  Side  of 
THE  Bladder  along  the  Course  of  the  Hypogas- 
tric Artery,  as  Seen  in  the  Newborn.     (Testut.) 
This  artery  in  the  adult  is  obliterated  in  the  greater 

part  of  its  course,  forming  a  cord. 

A,  superior  posterior  part     1,  vesico-rectal  peritoneum 


of  the  bladder  covered 
by  peritoneum. 
N,  inferior  anterior  part  of 
the  bladder  not  covered 
by  peritoneum. 

B,  seminal   vesicle. 

C,  rectum. 


forming  cul-de-sac. 

2,  right  ureter. 

3,  right  vas  deferens. 

4,  aorta. 

5,  right  Uiac  artery. 
6\  right  internal  iliac. 
7,  right  umbilical. 


Fig.  46. — Diagrajumatic  Drawing  Showing  the  Upper 
Surface  of  the  Bladder  in  the  I\L\le  as  Seen  from 
Above  When  Looking  Down  into  the  Pelvis. 
V,  upper  surface  of  bladder.  S,  sacrum. 

P,  symphysis  pubis.  /,  ileum. 


N.   B. — The  umbilical  artery  forms   most  of   the  obliter- 
vted  portion   of   what   is    generally   spoken   of   as  the  hj-po- 
gastric   artery.      It   comes    from    the  internal 
iliac. 


is  very  slight,  but  the  recto- 
vesical space  is  relatively  in- 
creased. In  depth,  the  urethral 
orifice  and  lower  part  of  the 
bladder  remain  fairly  constant 
in  position,  the  orifice  descend- 
ing slightly.  The  distended 
bladder  comes  into  more  inti- 
mate relation  with  the  side  wall 
of  the  pelvis,  being  in  apposi- 
tion with  the  hypogastric  artery, 
the  obturator  vessels  and  nerves, 
and  the  vas  deferens ;  while  a 
large  part  of  the  organ  becomes 


48     ANATOMY    OF    THE    T^KTXAKY    AXD    OEXTTO-rRTXAKY    TRACT 


intra-alxloiiiinal  and  is  in  relation  to  the  anterior  alxloininal  wall  for  a  vary- 
ing distance. 

Ligaments  of  the  Bladder. — The  ligaments  are  described  as  true  and  false. 
The  false  ligaments  are  merely  folds  of  peritoneum.  A  reflection  of  peritoneum 
from  the  apex  over  the  urachus  is  called  the  anterior  false  ligament.  This 
forms  the  upper  part  of  the  ix)sterior  wall  of  the  space  of  Iletzius.  The  peri- 
toneal reflection  from  the  side  wall  of  the  pelvis  to  the  lateral  borders  and 
superior  surface  of  the  bladder  are  the  lateral  false  ligaments.  They  dip  down 
slightly  into  the  space  between  the  bladder  and  pelvic  walls,  which  is  called  the 


Round. 

Lig. 


l;g.  DeepLjoig.ArX. 


Fig.  47. — The  Upper  Surface  of  the  Bladder  in  the  Female  Together  with  the  Other  Pelvic 
Organs  as  Seen  from  Above.     (Kelly.) 

paravesical  fossa.  Behind,  two  distinct  folds  of  peritoneum  cover  the  vas 
deferens  and  are  described  as  posterior  false  ligaments ;  these  correspond  to  the 
folds  of  Douglas  in  the  female,  and  form  the  lateral  boundaries  of  the  recto- 
vesical pouch. 

The  true  ligaments  consist  of  the  urachus  extending  from  the  apex  to  the 
anterior  abdominal  w^all;  the  lateral  processes  of  pelvic  fascia  firmly  fix  the 
lower  part  of  the  bladder  in  position.  In  front,  two  folds  of  this  fascia  extend 
from  the  symphysis  over  the  prostate  to  the  inferior  surface  of  the  bladder — 
the  pubo-prostatic  ligaments.  Within  these  folds  are  strands  o.f  muscular  fibers. 
The  lateral  ligaments  are  the  pelvic  fascia  as  it  passes  from  the  levator  ani  to 


THE   BLADDER 


49 


tlic  lihidilcv.      Tlic  l)as;il  sin-i"iic(>  is  fixed   in  ils  lower  jiart  Ijv  the  fascia  siir- 
roiiiKlinu'  llie  vcsicula'  seiiiinalcs  and  tennination  of  the  vas  deferens.      This 


Fig.  48. — Diagrammatic  Drawing  Showing  the  Base  and 
Sides  of  a  Dilated  Bladder  in  a  Pelvis  from  Which 
THE  Floor  and  the  Tissues  Constituting  the  Perineum 
'   Have  Been  Removed. 

The  lower  part  of  the  anterior   surface  is   just  seen.     The 
pelvis  is  in  the  lithotomy  position. 

P,  antero-inferior  or  pubic  surface. 
L,  lateral  surfaces. 
B,  base. 

contains  some  mnscnlar  fiber  and  extends  back- 
ward, gaining-  attachment  to  the  rectum  and  the 
front  of  the  sacrnm. 

Structure  of  the  Bladder. — The  serous  or 
])eritoneal  coat,  as  we  have  seen,  only  gives  a 
partial  covering  to  the  viscns.  The  muscular 
coat  is  very  thick  and  is  disposed  in  three  layers, 
which  are  somewhat  irregular.  The  outer  coat 
is  disposed  for  the  most  part  in  a  longitudinal 
or  vertical  direction,  some  of  the  fibers  from  the 
inferior  surface  being  continuous  with  the  mus- 
cidature  of  the  prostate,  while  in  front  they  are 
continuous  with  the  muscle  fibers  in  the  pubo- 
l)rostatic  ligament  (Fig.  50).  The  middle  coat 
is  not  found  as  a  complete  layer,  some  of  the 
fibers  being  horizontal  (Fig.  51)  and  some  longi- 
tudinal. Over  the  trigone  it  forms  a  continuous 
layt'v,  the  fibers  running  transversely,  while  near 
the  urethral  orifice  they  are  dispersed  in  a  cir- 


FiG.    49. — Change    in   the    Shape 

OF  THE  Bladder  while  Filling. 

(Poirier.) 


Fig.  50. — Longitudinal  Muscular 
Fibers  of  the  Anterior  Layer 
OF  the  Bladder  Wall.  (Sappey.) 

1,  longitudinal  fibers  of  the  anterior 

wall. 

2,  2,  the  same  fibers  which  are  continu- 

ous at  the  top  of  the  bladder  with 
those  of  the  opposite  side. 

3,  the    urachus    surrounded    by    the 

middle   anterior   fibers. 

4,  group  of  fibers  detaching  themselves 

from  the  principal  bundle  to  spread 
over  the  lateral  vesical  wall. 
6,  lateral    fibers    extending    out    from 
the  longitudinal. 

6,  antero-latcral  longitudinal  fibers. 

7,  aponeurosis    by    which    the    longi- 

tudinal medium  fibers  attach 
themselves  to  the  inferior  part  of 
the  symphysis  pubis. 


50     ANATOMY   OF    THE    URINARY   AND    GENITO-URTNARY    TRACT 

cular  nunnier.  The  inner  coat  is  a  tliin  stratum,  the  fibers  of  which  imui  htn^i- 
tndinally,  forming  the  internal  sphincter  (Fig.  52).  The  submucous  coat 
separates  the  mucous  membrane  from  the  inner  muscular  layer.  This  forms  a 
definite  layer,  except  over  the  trigrme  of  the  bladder,  whcix-  the  mucous  layer 
is  firudy  adherent  to  the  underlying  muscular  surface. 


Fig.  51. — Middle   or  Circular  Later  of  the 
Muscular  Wall  of  the  Bladder.     (Sappey.) 

1,  1,  circular   or  transverse  fibers  of  the   bladder 

forming  bundles  which  fit  into  one  another. 

2,  muscular  fibers  of  the  urachus. 

3,  3,  sphincter  of  the  bladder  embracing  the  be- 

ginning the  prostatic  portion  of  the  urethra. 

4,  cut  through  the  vesical  sphincter  showing  its 

thickness. 


Fig.  52. — Deep  Layer  of  the  Bladder  "\Y.\ll. 
(Sappey.) 

i,  1,  1,  streaked  bundles  of  fibers  extending  from 
the  top  toward  the  neck  of  the  bladder  divid- 
ing and  uniting  with  one  another. 

2,  2,  2,  elliptical  meshes  in  the  longitudinal  axis  re- 

sulting from  the  union  of  these  bundles. 

3,  muscular  fibers  at  the  urachus  separating  below 

and  continuous  with  the  other  fibers. 

4,  fibers  of  this  layer  forming  a  cylindrical  sheath 

wliich  extends  along  the  urethral  mucosa. 

5,  sphincter  of  the  bladder. 

6,  cut  section  of  the  prostatic  portion  of  the  ure- 

thra. 


The  mucous  layer  is  a  continuous  membrane  lining  the  "whole  internal  sur- 
face of  the  bladder,  and  is  continuous  with  that  of  the  ureters  and  urethra  ; 
it  is  disposed  in  folds  and  is  loosely  attached  to  the  bladder  wall,  e.xcejit  over 
the  region  of  the  trigone.  The  epithelium  is  a  transitional  stratified  tyj)e,  the 
same  as  that  lining  the  ureter. 

Cavity  of  the  Bladder. — In  the  empty  bladder,  this  is  said  to  assume  the 
shape  of  the  letter  "  Y  "  (Fig.  43).  The  stem  of  the  Y  is  represented  by  the 
beginning  of  the  j^rostatic  urethra  in  the  male.  Normally  in  the  living  body, 
the  interior  of  the  bladder  probably  never  possesses  this  shape,  but  would  b(; 
better  represented  as  a  slitlike  cavity  extending  from  the  a}K'X  almost  directly 


THE    BLADDER 


51 


backward  to  the  internal  meatus.  In  the  distended  bladder,  the  cavity  assumes 
an  oval  shape  (Fig'.  40). 

The  Orifices. — On  the  inner  surface,  three  openings  may  be  seen:  Above  and 
behind,  the  two  o])enings  of  the  ureters,  while  at  the  lowest  part  is  the  urethral 
internal  meatus  or  urethral  orifice  (Fig.  44).  Lines  joining  these  orifices 
\\(»uld  form  the  boundaries  of  an  equilateral  triangle,  the  sides  measuring  about 
an  inch  (2.5  c.c.)  in  the  empty  bladder.  This  triangular  area  is  called  the 
trigone. 

Vessels  and  Nerves. — The  blood  supply  of  the  bladder  comes  from  the  su- 
perior and  inferior  vesical  arteries.     The  veins  (Figs.  53  and  54)  form  a  dense 


Tiu.  53. — Veins  in  the  Male  Pelvis  after  the  Rectum  has  Been  Removed  and  the    Bladder 

Pulled  Down.     (Henle.) 

1,  vena  cava.  7,  plexus  of  Santorini. 

2,  external  iliac.  5,  vas  deferens. 

5,  internal  iliac.  9,  dorsalis  penis. 
4,  gluteal.  10,  internal  pubic. 

6,  obturator.  .                         11,  liladder. 
6,  sciatic. 


plexus  about  the  base  of  the  bladder  just  above  the  prostate  and  surrounding 
the  entrance  of  the  ureter.  This  ])lexus  communicates  freely  with  the  pros- 
tatic plexus  and  empties  into  tributaries  of  the  internal  iliac  veins.  The 
lymphatics  go  to  the  iliac  glands. 


52 


ANATOMY    OF    THE   URINARY    AND    GENITO-URINARY    TRACT 


The  nerve  supply   is   derived   from   the    ] .civic   plexus   of   the   sympathetic 
and  the  third  and  fourth  sacral  nerves.     T\n-  former  supi-lics  the  upper  jx.r- 

tion  and  the  latter  its  neck 
and  hase. 


Fig.  54. — Veins  about  a  Female  Bladder  as  Seen  fkom 
THE  Front.     (Poirier.) 
They  empty  into  the  internal  iliac  principally  through  the 
vesical  and  internal  pudic  vein. 


THE   URETHRA 

Fig.  55.  — Entire  Length  of  the 

The  male  urethra  is  a  canal  extending  from       Male  Urethra  from  the  Neck 

, -,  T  .      1     ,     1     ,     T   ii   ^  ,1^  ;+    OF  the  Bladder  to  the  External 

the  bladder  to  the  external  meatus,     in  the  male  it      Urinary  Meatus.    (Taylor.) 
measures  about  eight  inches  in  length,  and  passes 

through  the  prostate,  compressor  urethra?  muscle  and  corpus  spongiosum  of  the- 
penis"(Fig.  55).  In  its  course  from  the  bladder  as  far  as  the  suspensory  liga- 
ment, the  urethra  forms, a  continuous  curve  with  the  convexity  backward.  At 
this  point  a  reverse  curve  appears  when  the  penis  is  flaccid.     The  whole  course 


TITK    rRKTIIRA 


53 


of  flic  cniiiil    tlius   resembles  the  letter  ""  S  "    (Fig.    56).      When  the  penis  is 
erect  (ir  hcM  in  position  for  the  j^assage  of  an  instrument,  the  reverse  curve  is 


Fk;.  56. — Curves  of  the  Urethea  When  the  Organ  is  Flaccid,  also  the  Fixed  Portion  of  the 

Canal.      (Testut.) 


1,  symphysis  pubis. 

2,  neck  of  bladder. 

3,  lowest  point  of  the   bulb 

the  urethra. 

4,  angle  of  the  penis. 
6y  bladder  cavity. 

6,  prostate. 

7,  vas  deferens. 

On  the  right  of  the  figure 
out  rapidly  the  distance  in  a 


5,  ejaculatory  duct. 

9,  veru  niontanum. 

of       10,  bulb  of  urethra. 

a,  a,  the  plane  of  the  superior 

strait  of  the  pelvis. 

b,  b,  axis  of  the  symphysis. 

c,  c,  horizontal  line  drawn  through 

the  neck  of  the  bladder, 
is  to  be  found  a  scale  in  the  metric  system  which  permits  the  reader  to  make 
vertical  line  which  separates  different  parts  marked  on  the  cuts. 


d,  d,  horizontal  line  passing  through 

the  lowest  edge  of   the   sym- 
physis. 

e,  e,  horizontal  Kne  drawn  through 

the  penile  angle. 
/,  /,  horizontal  line  drawn  through 
lowest  part  of  the  membranous 
canal. 


(il>] iterated,  the  anterior 
limb  of  the  posterior 
curve  being  prolonged 
f  c  r  w  a  r  d  and  upward 
(Fig.  57). 

The  urethra  is  di- 
vided into  three  portions 
for  descriptive  purposes: 
the  prostatic,  the  mem- 
branous and  the  spongy 
portion. 

The  Prostatic  Ure- 
thra.— This  part  extends 


Fig.  57. — Curve  of  the  Urethra  When  the  Penis  is  Erect  or 
Held  in  Position  for  the  Passage  of  Instruments.     (Taylor  ) 


54     ANATOMY   OF    THE    URINARY   AND    GENITO-URIXARY    TRACT 


throngli  the  prostate  jiland,  niid   is  sliohtly  curved  in  direction,  the  convexity 
of  the  curve  being  backward  (Fig.  58).     It  is  one  and  one  quarter  inclies  (3.1 

ciii.j  ill  length,  and  is 
somewhat  s])indle-shaj)ed. 
Tlie  dilated  middle  por- 
tion is  the  widest  part  of 
the  whole  urethra.  On 
cross  section  it  is  horse- 
shoe-shaped, with  the  con- 
v  exit  y  forward .  The 
posterior  wall  or  floor 
contains  a  median  ridge, 

C.S.  ^- ^^^^^^^^^^^k^^Z^i^T^    \  \  the    veru    montanum,    on 

the  summit  of  which  is  a 
small  depression.  This 
depression  is  the  opening 


Fig.  58. — Membranous  Urethra  and  Its  Relation  to 
THE  Triangular  Ligament. 

M.  U,  limits  of  membranous  urethra. 

D.T,  deep  layer  triangular  ligament. 

S.T,  superficial  layer  of  triangular  ligament. 

c.c,   corpus   cavernosum. 

C.S,  corpus  spongiosum. 

C.F,  Colles'  fascia. 

B.  U,  bulbous  urethra. 

P,  prostate. 

E.D,  ejaculatory  duct. 

S,  symphysis. 

of  the  sinus  pocularis,  a  small  cul-de-sac 
which  extends  into  the  jirostate  for  about 
one  quarter  of  an  inch,  and  is  analogous  in 
the  male  with  the  nterns  in  the  female.  On 
either  side  of  its  opening  into  the  nrethra, 
are  the  openings  of  the  common  ejaculatory 
ducts.  Abont  the  veru  montanum,  are  the 
openings  of  the  ducts  of  the  prostate,  while 
on  either  side  is  a  groove  called  the  prostatic 
sinus. 

The   Membranous   Portion. — This   part 
extends  from  the  prostate  to  the  bulb  of  the 


Fig.  59.— Genito-urin.^ry  Sinus  in  the 
Male,  the  Prostate  H.wing  Been 
Opened  Anteriorly  .vnd  Its  Lat- 
eral Lobes  Retracted.     (Testut.) 

At  this  point,  the  posterior  urethra  is 
seen  in  direct  communication  with  the 
bladder  and  with  the  ejaculatory  ducts. 

1,  the  Ijladder. 

2,  urethra. 
S,  prostate. 

4,  veru  montanum. 

5,  frenum  of  the  veru  montanum. 

6,  urethral  crest. 

7,  prostatic  utricle  (sinus  pocularis). 

8,  orifices  of  the  ejaculatory  ducts. 

9,  prostatic  fossette. 

10,  lateral  depressions  of  the  veru  mon- 
tanum. 


THE   UKETHRA 


55 


-.—  2 


penis.  Tt  is  about  an  inc-li  (2.5  cm.)  from  the  symphysis  pubis,  and  lies 
liclwcc'U  tlic  two  layers  of  the  triangular  ligament.  The  anterior  wall  is 
abmil  one  half  inch  in  length,  while  the  posterior  wall  is  a  little  more.  This  is 
(hio  to  the  fact  that  the  urethra  opens  into  the  bnlb  by  an  oblique  opening.  It 
is  completely  surrounded  by  the  compressor  urethral  muscles,  while  on  either 
side  are  (^owper's  glands.  At  its  commencement,  it  is  immediately  in  front 
of  the  rectum,  but  in  its  course  it  curves  forward  while  the  rectum  curves  back- 
ward ;  hence  at  its  termination  there  is  an  interval  of  about  half  an  inch  be- 
tween the  two.  At  its  termination 
the  antericn-  portion  has  passed 
through  tlie  triangular  ligament  be- 
fore entering  the  bulb,  and  here 
there  is  a  small  area  with  no  im- 
mediate covering  and  it  can  be  eas- 
ily punctured  by  an  instrument 
(Fig.  58). 

The  Spong-y  Portion. — The 
s])()ngy  portion  extends  from  the  an- 
terior layer  of  the  triangular  liga- 
ment to  the  meatus  and  is  about  six 
inches  (15  cm.)  in  length.  It  is  sur- 
rounded by  the  erectile  tissues  of  the 
corpus  spongiosum,  the  greater  part 
of  the  tissue  being  behind  the  urethra 
in  the  bulb,  and  in  front  and  on  the 
side   of  the   glans. 


The   caliber  of 


this    part    is    not    uniform    through-    Fig.   60.  — The   Natural   Dilatations   and   Nar- 

ROWINGS    OF    THE    UrETHRA.       (Testut.) 


out  (Fig.  60),  thus  it  is  larger  in 
tlie  part  surrounded  by  the  bulb,  be- 
comes smaller  in  the  corpus  spongi- 
osum, and  as  it  enters  the  glans  it 
becomes  markedly  dilated,  the  di- 
lated portion  being  known  as  the 
fossa  navicular  is.  The  external 
meatus  is  vertical  in  direction,  and  is 
the  narrowest  and  least  dilatable  por- 
tion  of   the   wdiole   canal.     Therefore, 


1,  the  bladder. 

2,  neck  of  bladder. 

3,  eoUar  of  the  bulb. 

4,  meatus. 

The  natural  dilatations  are: 

5,  of  the  prostate. 

6,  of  the  bulb. 

7,  of  the  fossa  navicularis. 
The  narrowings  are: 

5,  of  the  membranous  urethra. 
9,  of  the  penile  portion. 


it   will   be   seen   in   Fis;.    0(1    that   the 


three   dilatations   of  the   canal   are   the   fossa    navicularis,    the   bulb   and   the 
prostate. 

The  Structure. — The  urethra  consists  of  a  muscular,  submucous  and  mucous 
layer.  The  external  coat  is  a  thin  layer  of  unstriped  muscle,  continuous  with 
the  musculature  of  the  bladder  and  prostate.     The  submucous  layer  consists 


56     ANATOMY   OF   THE   URINARY   AND   GENITO-URINARY   TRACT 


of  vascular  and  erectile  tissue.  This  is  found  not  only  in  the  spongy  portion 
bnt  also  in  the  niemhranous  and  ])i'ostatic  portions.  The  mucons  membrane 
is  a  thin  delicate  layer  lined  by  transitional  epithelia  continuous  with  the 
bladder  and  urethra.  The  superficial  epithelium  of  the  mucous  mendn-ane  is 
columnar,  except  at  the  meatus  and  fossa  navicularis,  Avlierc;  it  becomes 
squamous.     The  meudu'ane  is  disposed  in  folds  during  the  flaccid  condition  of 

the  organ,  and  on  the  internal  surface 
are  the  orifices  of  numerous  glands. 
Some  of  these  in  the  mend)ranous  and 
the  first  part  of  the  spongy  portion 
are  called  the  glands  of  Littre.  The 
ducts  of  Cowper's  glands  open  into 
the  bulbous  portion  near  its  commence- 
ment. 

The  urethra  in  the  female  ( Fig. 
61)  is  a  short  canal  about  one  and  one 
half  inches  (3.7  cm.)  in  length,  im- 
bedded in  the  anterior  vaginal  wall. 
The  external  meatus  is  situated  be- 
neath the  clitoris  and  has  the  shape  of 
an  inverted  "  V."  The  whole  urethra 
in  the  female  morphologically  repre- 
sents that  portion  of  the  prostatic  ure- 
thra in  the  male  which  is  situated  be- 
tween the  bladder  orifice  and  the  sinus 
pocularis. 

The  Blood  Supply. — The  prostatic  portion  is  supplied  by  branches  of  the 
middle  hemorrhoidal  artery,  the  membranous  portion  by  the  inferior  hemor- 
rhoidal and  transverse  perineal  arteries,  the  spongy  portion  by  the  arteries 
which  go  to  the  penis.  The  venous  return  is  in  part  by  the  dorsal  vein  of  the 
penis,  and  in  part  directly  by  the  prostatic  plexns.  The  lymphatics  of  the 
membranous  and  spongy  portion  go  to  the  inguinal  glands,  while  those  of  the 
prostatic  portion  go  to  the  iliac  glands. 

The  nerve  supply  of  the  urethra  is  from  the  superficial  perineal  and  dorsal 
nerves  of  the  penis,  and  also  branches  from  the  hypogastric  plexus. 


Fig.      61.  —  Transverse     Vertical     Section 

THROUGH    THE    FeMALE    UrETHRA. 

Skene's  glands  are  near  its  end.    Compare  it 
with  Fig.  55,  the  male  urethra. 


COWPER'S    GLANDS 

These  are  two  small  bodies  about  the  size  of  a  pea,  placed  on  either 
side  of  the  membranous  urethra,  between  the  apex  of  the  prostate  and  the 
bulb  of  the  corpus  spongiosum  (Fig.  62).  The  gland  consists  of  numerous 
branching  tubules,  which  are  arranged  in  small  lobules.     The  excretory  duct 


SCROTUM 


57 


of  each  gland  passes  forward  between  the  urethra  and  the  substance  of  the 
bnlb  for  about  an  inch  (2.5  cm.),  opening  by  a  minute  orifice  on  the  floor 
of  the  iiretlira.  The  glands  of 
IJniiholiii,  in  the  female,  arc 
I  he  analogues  of  the  glands  of 
( 'owper  in  the  male.  They  are 
slightly  larger  than  the  latter 
glands,  and  open  outside  of  and 
external  to  the  hymen  just  be- 
neath the  labia  minora. 


10 ~ 


Fig.  63. — Schematic  Vertical  Trans- 
verse Cut  through  the  Scrotum, 
Showing  the  Formation  of  the 
Sac.     (Poirier.) 

1,  skin,  integument. 

2,  outer  layer  of  dartos. 
S,  inner  layer  of  dartos. 

4,  areolar  (cellular)  tissue. 

5,  middle  spermatic  or  cremasteric  layer. 
6",  internal  spermatic  or  fibrous  tunic. 
7,  cellular  tissue  between  the  two  sides 

of  the  scrotum. 
<S,  penile  dartos  sheath. 
9,  suspensory  ligament  of  penis. 
10,  raphe. 

Note. — The  outer  layer  of  spermatic 
fascia  is  not  shown  in  this  figure. 


4 


6 


7     4 


Fig.  62. — Cowper's  Glands. 
(After  Testut  and  Jacob.) 

1,  anterior  layer  of  the  deep  perineal  fascia  (triangular  lig 

ment) . 

2,  the  fascia  incised  and  drawn  down. 

3,  Cowper's  gland  on  the  right  side  freed  and  delivered. 

4,  artery  of  Cowper's  gland. 

5,  Cowper's  gland  on  the  left  side  covered  by  fascia. 

6,  membranous  urethra  cut  through . 

7,  bulbo-urethral  artery. 


SCROTUM 

The  scrotum  is  the  bag  in  which  the 
testes  and  a  part  of  the  spermatic  cord  are 
contained  (Fig.  63).  Its  outer  surface  is 
wrinkled  in  appearance,  light  brown  in  color 
and  is  divided  in  two  halves  by  an  elevated 
narrow  band  called  a  raphe. 

Septum  Scroti. — The  two  sides  of  the 
scrotiun  are  further  separated  above  by  a 
continuation  of  the  dartos  sheath  around  the 
testes  and  up  their  inner  sides  to  the  penis, 
in  which  intervening  space  is  a  layer  of  cel- 
lular tissue. 

x\bove  the  penis  is  the  suspensory  liga- 
ment which  binds  the  organ  to  the  pubes. 

The  scrotum  is  composed  of  several 
layers,    and    within    it    are    the    testes    and 


58     ANATOMY    OF    THK    URINARY   AND    GENITO-URINARY    TRACT 

tlioii"  e])i<litlyiuc'S,  the  fonucr  siiiTouiuled  by  a  tunica  vaiiiiialis.  'V\u-  layers  of 
the  tunica  vaginalis  are  not,  jn-operly  speaking,  a  part  of  the  scr(jtinn.  Tlie 
scrotal  layers  are : 

The  skin  (integument). 

The  dartos  sheath,  ■which  is  a  red  layer  of  fascia  continuous  with  the  dai'tn.s 
sheath  of  the  penis  and  with  the  su])erticial  fascia  of  the  perineum  and  abdomen. 
It  contains  elastic  tissne  and  nnstriped  muscle  fibers. 

The  cellular  tissue  layer. 

The  outer  layer  of  spermatic  fascia  which  is  the  extension  downward  of  the 
intercohunnar  fascia. 

The  middle  layer  of  spermatic  fascia,  Avhich  is  the  extension  downward  oi 
the  cremasteric  muscle  and  fascia. 

The  inner  spermatic  fascia,  Avhicli  is  an  extension  of  the  transversal  is  and 
is  pushed  dow'n  during  the  descent  of  the  testes. 

Tunica  Vaginalis. — This  consists  of  a  parietal  and  visceral  layer  of  serous 
membrane,  forming  a  closed  sac.  The  visceral  layer  invests  the  body  of  the 
testicle  except  behind,  where  the  ducts  and  vessels  are  attached,  being  here  con- 
tinuous with  the  parietal  layer  that  lines  the  inner  wall  of  the  scrotum. 


Spermatic  pord. 


Artery  of 
cord. 


TESTES 

The  testes  are  two  oval-shaped  bodies  situated  on  either  side  of  the  scrotum 
(Fig.  64)  ;  they  are  separated  from  one  another  by  a  partial  septum  extending 

across  the  scrotum  from  before  backward. 
They  are  about  one  and  one  half  inches 
(3.7  cm.)  long,  one  inch  (2.5  cm.)  in  diam- 
eter from  before  backward,  and  three  quar- 
ters of  an  inch  (1.87  cm.)  from  side  to  side. 
Their  long  axis  extends  from  below  upAvard 
and  slightly  outward  and  forward ;  the  left 
is  normally  lower  than  the  right.  On  the 
upper  and  posterior  borders,  extending  also 
slightly  on  to  the  outer  surface,  is  placed  a 
crescentic-shaped  body  called  the  epididymis. 
The  enlarged  upper  end  of  this  is  the  globus 
nuijor  (head),  and  the  lower  end  is  the  globus 
minor  (tail),  the  intermediate  portion  being 
known  as  the  body  of  the  epididymis.  The 
^  ^      ^  ,.  globus  maior  is  attached  to  the  testes  bv  the 

Fig.  64. — The  TtinicaVaginalis^.  .  .         ." 

Opened,  Exposing  the  Testis  with     visceral  layer  of  the   tuuica   vaginalis,    and 

THE   Visceral  Layer  Covering   It       ^jg^    ^^^    ^^l^    ^^^^^^    emerging    from    the    testes 
AND  THE  Parietal  Layer  Lining  the  _     '  . 

Scrotal  Tissues.    (Gray.)  at    its    upper    end     (vasa    eflferentia).     The 


Tunica  vaginalis, 
parietal  layer. 


TESTES 


59 


o-lol)ns  minor  is  attached  to  the  lower  part  of  the  testes  by  areolar  tissue  and 
the  visceral  layer  of  the  tunica  vaginalis.  The  intervcniing  portion  or  body  is 
se]iarated  from  the  ])()steri(jr  border  of  the  testes  Ijy  an  infolding  of  the  tnnica 
between  it  and  the  testes,  forming  the  digital  fossa,  seen  from  the  outer  aspect. 
From  the  up]ier  end  of  the  testes  near  the  globus  major,  are  usually  found  two 
small  bodies — one  sessile,  and  one  pedunculated.  The  former  is  a  remnant  of 
the  Woltlian  tubules,  corresponding  to  the  parovarium  in  the  female.  The 
])edunculated  one  is  derived  from  the  Wolffian  duct,  representing  the  epoophoron 
in  the  female. 

The  Tunica. — The  scrotum  is  lined  by  a  serous  sac  derived  from  the  perito- 
neum (tunica  vaginalis).  In  the  posterior  part  of  the  scrotum,  this  is  reflected 
on  to  the  epididymis  and  tes- 
ticle, surrounding  them  ex- 
cept where  they  are  in  con- 
tact with  each  other,  and  pos- 
teriorly where  the  vessels 
pass  to  or  from  the  testes  and 
e})ididymis.  The  part  of  the 
sac  lining  the  scrotum  is 
called  the  parietal  layer  and 
the  part  covering  the  testes 
is  called  the  visceral  layer 
(Fig.  64). 

Structure. — The  testis 
has  a  complete  fibrous  cov- 
ering, the  tunica  albuginea, 
^vhich  forms  the  thickened 
ridge  on  the  posterior  border 
(mediastinum).  From  this 
fibrous  ridge,  septa  pass  into 
the  glands  and  divide  it  into 
compartments  (Fig.  65)  ;  the 
glandular  structure  is  found 
in  these  compartments  and 
consists  of  a  great  number  of 


Fig.  65. — Schematic  Draaving,  Showing  the  Anatomical 
Arrangement  of  the  Testicle  and  the  Epididymis. 
(Testut.) 

1,  tunica  albuginia. 

2,  the  septa  of  the  testis. 
S,  a  lobule  of  the  testis  ending  in  a  straight  duct. 

4,  body  of  Highmore  with  the  rete  vasculosum  testis. 

5,  efferent  cones. 

6,  duct  of  the  epididymis. 

7,  aberrant  vas  of  Haller. 
S,  vas  deferens. 


minute  ducts  called  semin- 
iferous tubules.  These  unite 
to     lV)rui     the     tubuli     recti, 

which  pass  into  the  mediastinum,  where  they  enter  a  complicated  canal 
work  called  the  rete  testis.  From  this  canal  system,  fifteen  to  twenty  small 
ducts  pass  into  the  globus  major.  .  In  the  globus  major  these  small  ducts  be- 
come markedly  convoluted,  forming  conii  vasculosi,  and  finally  open  into  one 


60     ANATOMY   OF    TIIK    URINARY   AND    OENITO-URINARY   TRACT 


duct  called  the  canal  of  the  ei)i(lidyiiiis.      This  in  its  conrse  is  greatly 
luted  and  coiled  npon  itself  to  form  the  body  and  especially  the  globus 
If  stretched  out,  it  wonld  measure  about  hventy  feet.     The  canal  of  the  c 
mis   emerges    from    the   globus    minor 
as  the  vas  deferens  (Fig.  GG). 

!--■ 

19      11^ 

■\  /f     51  p 

Tunica  Vaginalis. 
Tunica  Albuginea. 
Its  Septa. 


convo- 
minor. 

nididv- 


FiG.  66. — Vertical  Section  of  the  Testis  and       Fig.  67. — Blood  Supply  of  the  Testis  and  Cord. 


Epididymis,  Showing  the  Line  of  Reflec- 
tion of  the  Visceral  Layer  of  the  Tunica 
Vaginalis,  the  Tunica  Albuginea  with  Its 
Septa,  the  Rete  Testis,  Mediastinum, 
THE  Epididymis  and  Vas  Deferens.  (After 
Gray.) 


(After  Charpy.) 

1,  spermatic  artery. 

2,  cremasteric  artery. 
S,  artery  of  the  vas. 

4,  anterior  group  of  veins. 

5,  posterior  group  of  veins. 

6,  venous  anastomosis  with  the  superficial  veins. 


Blood  Supply. — The  testicle  is  supplied  with  blood  by  the  spcrmntic  art  cry. 
This  vessel  has  a  long  course,  arising  from  the  aorta  just  below  the  renal  ar- 
teries ;  it  extends  downward  in  the  abdominal  cavity  to  the  internal  abdominal 
ring,  thence  passing  down  the  inguinal  canal  in  the  spermatic  cord ;  it  enters 
the  testes  at  the  upper  part  of  its  posterior  border  (Fig.  67).  Within  the 
gland  it  is  distributed  along  the  iibrous  septa  and  beneath  the  tunica  albuginea. 

The  spermatic  vein  forms  a  plexus,  the  pampiniform,  at  the  posterior  part 
of  the  testis  and  epididymis  which  passes  upward  and  forward  to  the  front 
part  of  the  cord,  where  it  is  most  marked.  The  vein  then  passes'  through  the 
external  abdominal  ring,  the  inguinal  canal  and  the  internal  ring  and  empties 
into  the  vena  cava  on  the  right  side  and  the  renal  vein  on  the  left. 

The  Spermatic  Cord  and  Vas  Deferens. — The  spermatic  cord  is  about  four 
inches  in  length,  and  extends  from  the  globus  minor  of  the  epididymis  to  the 


TESTES 


61 


internal  abdominal  ring,  at 
vas  deferens,  or  excretory 
the  aorta ;  the  artery  and 
vein  (»f  the  vas  deferens; 
t]ie  cremasteric  artery  from 
the  deep  epigastric ;  the 
spermatic  veins;  the  sper- 
matic nerve  plexus; 
liranches  of  the  ileo-inguinal 
and  genito-criiral  nerves, 
a  n  d  1  y  m  p  h  a  t  i  c  s.  These 
structures  are  bound  to- 
gether by  loose  fibrous  and 
fatty  tissue,  and  are  in- 
vested by  the  fasciae,  already 
spoken  of  in  considering  the 
anatomy  of  the  scrotum, 
that  are  carried  down  by 
the  testicle  in  its  descent. 
The  vas  deferens  lies  below 
and  behind  the  larger  an- 
terior group  of  veins  and 
the  spermatic  artery.  The 
mass  of  veins  on  the  front 
of  the  cord,  called  the  pam- 
piniform plexus,  unites  into 
a  single  trunk,  the  sper- 
matic vein,  on  the  right  side 
passing  into  the  inferior 
vena  cava  and  on  the  left 
side  into  the  left  renal  vein. 
The  artery  of  the  vas  defer- 
ens, derived  from  the  in- 
ferior vesicle,  is  in  direct 
relation  with  it ;  whereas  the 
s])ermatic  artery  follows  a 
tortuous  course  through  the 
cord.  The  nerves  are  dis- 
tributed throughout  the  cord, 
with  the  exception  of  fila- 
ments from  the  hypogastric 
plexus,  which  invest  the  vas 


which  place  they  separate.     It  is  made  up  of  the 
duct   of  the  testicle ;    the   spermatic   artery   from 


Fig.  68. — Coverings  of  the  Testes,  Seen  from  in  Front. 
(After  Testut.) 

On  the  right  side  the  scrotum  and  dartos  have  been  removed 
to  show  the  cremasteric  muscle  and  fascia.  On  the  left  side 
the  sheath  of  the  cord  and  the  tunica  vaginalis  have  been  cut 
through  over  the  testis  and  retracted  showing  the  gland  and 
its  epididymis;  whereas  higher  up  another  incision  shows  that 
the  peritoneo-vaginal  process  has  not  closed  at  this  point. 

A,  the  root  of  the  organ  pulled  3,  skin  of  organ. 


upward. 
a,  urethra. 
a',  a',  corpora  cavernosa. 

B,  inguinal  canal  on  the  right 

side. 

C,  scrotum  on  the  right  side. 

D,  scrotum  on  the  left  side. 

E,  and  F,  testis  and  epididj^- 

mis  on  the  left  side. 
G,  spermatic  cord. 
r,  raphe  of  scrotum. 
2,  dartos. 


4,  dartos  layer. 

J,  dartos  of  septum. 

6',  cellular  layer. 

7,  internal  and  external  bun- 
dles of  cremasteric  muscle. 

8,  cremasteric  layer  of  scro- 
tum. 

9,  fibrous  layer. 

10,  parietal    layer   of    tunica 
vnginalis. 

11,  jjeritoneo-funicular  proc- 
ess open. 


62     ANATOMY    OF    THE    URINARY   AND    GENITO-URINARY    TRACT 


ill  a  rich  network.     The  l_vii)])hatic  vessels  empty  into  the  g-lands  snrronnding 
the  lower  part  of  the  aorta  and  one  gland  lying  over  the  external  iliac  artery. 


■  m 

I 


30        29      28  27 

Fig.  69. — The  Vas  Deferens  Extending  through  the  Inguin.\l  Can.\l  and  along  the  Side  of  the 

BL.A.DDER    TO    THE    EjACULATORY    DuCTS.       (Spalteholz.) 


1,  thetestis. 

16,  first  sacral  vertebra. 

2,  the  male  organ. 

17,  sigmoid. 

3,  the  epidid5'mis. 

18,  mesorectum.                                   * 

4,  the  erector  penis. 

19.  ureter. 

B,  vas  deferens. 

20,  ampulla  of  the  vas. 

6,  superior  ramus  of  the  pubcs. 

21,  recto-vesical  space. 

7,  apex  of  the  bladder. 

22,  sacral  flexure  of  the  rectum. 

8,  parietal  peritoneum. 

23,  diaphragm  of  the  pelvis  (levator 

ani  muscle) 

9,  obliterated  hypogastro-umbilifal  artery. 

24,  external  sphincter  muscle. 

10,  peritoneum  over  bladder. 

25,  anus. 

11,  body  of  the  bladder. 

26,  perineal  flexure  of  the  rectum. 

12,  seminal  vesicle. 

27,  prostate. 

IS,  iliac  artery. 

28,  perineum. 

14,  iliac  vein. 

29,  inferior  ramus  of  the  ischium. 

15,  mesosigmoid. 

SO,  scrotum. 

THE    PKOSTATE    GLAND  63 

The  spermatic  cord  (Fig.  68)  derives  its  coverings  from  different  layers  in 
the  abdominal  wall,  from  within  outward,  the  process  of  peritoneum,  called  the 
funicuhir  ])rocess,  being  continuous  below  with  the  tunica  vaginalis.  Out- 
side of  tliis  is  the  infundibuliform  or  transversalis  fascia,  the  cremasteric 
fascia  from  the  internal  oblique,  and  the  intercolumnar  fascia  from  the  ex- 
ternal oblique. 

The  vas  deferens  (Fig.  69)  is  a  small  duct  which  conveys  the  semen  from 
the  testes  to  the  urethra.  It  can  be  felt  as  a  small,  cordlike  structure  running 
up  the  j^osterior  part  of  the  spermatic  cord ;  its  appearance  is  wdiite  and  glis- 
tening. A  small  portion  of  its  course  is  within  the  scrotum,  where  it  ascends 
on  the  inner  side  of  the  epididymis.  It  then  passes  through  the  inguinal  canal 
with  the  other  constituents  of  the  spermatic  cord  to  the  internal  abdominal  ring. 
Here  it  winds  round  the  deep  epigastric  artery,  passing  downward  and  back- 
ward on  the  side  wall  of  the  pelvis ;  it  crosses  the  obliterated  hypogastric  artery 
and  obturator  vessels  and  nerves.  Crossing  inward  to  its  termination,  it 
raises  in  its  course  a  fold  of  peritoneum,  crosses  the  ureter  just  before  the  ter- 
mination of  the  latter,  and  then  turns  dow^nward  in  close  apposition  to  the 
base  of  the  bladder  to  the  inner  side  of  the  vesicul^  seminales,  to  the  base  of 
the  prostate,  wdiere  it  terminates  by  joining  the  duct  from  the  vesicular  seminales 
to  form  the  common  ejaculatory  duct. 

The  Vesiculse  Seminales  (Fig.  3). — These  are  situated  on  the  basal  sur- 
face of  the  bladder,  extending  from  over  the  lower  part  of  the  ureter  above  to 
the  base  of  the  prostate  below,  running  external  to  the  terminal  portion  of  the 
vas.  The  vesicle  forms  a  convoluted  mass  about  two  inches  (5  cm.)  in  length, 
and  in  reality  is  a  single  tube,  coiled  upon  itself  and  held  together  by  con- 
nective tissue.  When  opened  out,  it  measures  five  or  six  inches  in  length.  The 
vesiculffi  seminales  lie  almost  in  apposition  at  their  lower  end  but  above  are 
widely  separated  and  spread  outward  almost  horizontally  between  the  base 
of  the  bladder  and  the  rectum.  The  lower  ends  open  into  the  vas  to  form  the 
common  ejaculatory  duct.  They  are  developed  as  diverticula  of  the  vas  deferens, 
as  the  gall-bladder  is  developed  from  the  common  bile  duct. 

Common  Ejaculatory  Duct. — This  duct  is  a  short  canal,  three  quarters  of 
an  inch  (1.8  cm.)  in  length,  extending  downward  in  a  cleft  of  the  prostate 
gland  to  the  urethra  where  it  opens  into  or  at  the  margins  of  the  sinus  pocularis. 
Tlie  sinus  pocularis  is  a  small  depression  just  below  the  highest  part  of  the 
veru  montanum,  and  is  the  analogue,  in  the  male,  of  the  uterus  in  the  female. 

THE   PROSTATE   GLAND 

The  prostate  gland  is  situated  in  tlie  male  pelvic  cavity  beneath  the  bladder, 
and  completely  surrounds  the  orifice  of  the  urethra.  It  is  about  one  and  one  half 
inches  (3,7  cm.)  in  its  transverse  diameter,  about  an  inch  (2.5  cm.)  from  be- 


64     ANATOMY    OF    THE    URINARY   AND    GENTTO-URINARY    TRACT 

fore  backward,  and  al)ont  one  and  one  quarter  inelies  (-3.1 2  cm.)  from  alj(jvG 
downward.  In  sliape  it  is  said  to  resemldo  a  Spanisli  chestiuit,  and  has  a  base 
directed  npward,  an  apex  directed  downward,  a  posterior,  an  anterior,  and  two 
lateral  surfaces.  The  base  is  firmly  fixed  to  the  under  surface  of  the  bladder 
(Fig.  TO),  the  musculature  of  the  one  being  directly  continuous  with  that  of 
the  other.  There  is  only  a  shallow  groove  between  the  circumference  of  this 
surface  and  the  bladder  where  they  are  not  structurally  continuous.  This 
groove  is  filled  by  several  large  veins. 


Fig.  70. — Profile  View  of  the  Side  of  the  Unopened  Prostate.     (Albarran.) 


pubis. 

suspensory  penile  ligament, 
subpubic  ligament, 
root  of  corpus  cavernosum. 
seminal  vesicle, 
rectum, 
prostate. 

compressor  urethra  muscle,  striated  mus- 
cle of  Henle. 


9,  sphincter  ani  nauscle. 

10,  deep  transverse  perinei  muscle. 

11,  superficial  transverse  perinei. 

12,  cut-off   muscle,    compressor   urethra   or 
muscle  of  Guthrie. 

13,  accelerator  muscle. 

14,  preprostatic  layer  of  pelvic  fascia. 

15,  transverse  pelvic  ligament. 
IG,  muscle  of  Wilson. 


Note. — The  muscles  of  Guthrie,  Wilson  and  Henle  are  all  associated  and  their  fibers  arc  connected. 


The  apex  is  the  lowest  portion  of  the  gland,  and  rests  on  the  sujierior  or 
deep  layer  of  the  triangular  ligament.  The  posterior  surface  is  somewhat  tri- 
angular and  is  separated  from  the  rectum  by  pelvic  fascia.  The  lateral  surfaces 
are  convex  from  behind  forward  and  from  below  upward.  They  are  covered 
with  pelvic  fascia  which  separates  them  from  the  levator  ani.  The  anterior 
surface  is  narrow  and  rounded  in  its  lower  part.  In  front  and  a  little  above 
cne  apex  on  this  surface,  the  urethra  leaves  the  gland.  The  anterior  surface 
vccnpies  the  space  between  the  two  levator  ani  muscles,  and  is  covered  by  pelvic 


THE    TROSTATE    GLAND 


65 


fascia,  a  portion  of  which  forms  the  piibo-prostatic  ligament.  The  common 
ducts  enter  tlie  prostate  at  the  upper  part  of  the  posterior  surface,  running 
(Idwnward  and  forward  to  o])en  into  the  prostatic  urethra.  Tlie  triangular  por- 
tion of  tlio  gland  l)('[\vc('n  these  dncts  and  the  urethra  is  called  the  middle  lolje 
(Fig.  71). 


Fig.  71. — The  Lobes  of  the  Prostate  and  the  Perineal  Fascias.     (Albarran.) 

The  so-called  middle  lobe  is  seen  clearly  behind  the  urethra  and  in  front  of  the  ejaculatory  duct. 
This  part  of  the  gland  bounded  by  the  bladder,  urethra  and  ejaculatory  ducts  is  supposed  to  be  the 
principal  part  of  the  gland  involved  in  prostatic  hypertrophy.  It  is  simply  the  portion  of  the  lateral 
lobes  above  the  ejaculatory  duct. 


1,  preprostatic  layer  of  pelvic  fascia. 

2,  external  sphincter,  prostatic  segment. 

3,  subpubic  ligament. 

4,  dorsal  vein. 

5,  supraurethral  fascia. 


6,  transverse  ligament  of  perineum. 

7  and  8,  leaflets  of  the  aponeurosis  of  Denon- 

villiers. 
9,  compressor  urethrse  or  cut-off  muscle. 
10,  infraurethral  layer  of  fascia. 


The  Relations. — It  lies  in  front  of  the  rectum  and  one  and  one  half  inches 
(.3.7  cm.)  from  the  ani;s.  It  is  situated  behind  the  lower  part  of  the  symphysis, 
at  a  distance  of  about  an  inch.  The  bladder  is  above  it,  the  superior  layer  of  the 
triangnlar  ligament  below  it,  and  the  levator  ani  muscle  on  either  side.  Inune- 
d lately  surrounding  it  is  pelvic  fascia  forming  a  thick  layer.  A  line  of  cleavage 
is  made  in  this  layer  by  the  prostatic  plexus  of  veins  which  surround  the  sides 
and  base  of  the  gland  (Fig.  72).  The  portion  of  fascia  outside  of  these  veins 
is  described  as  the  external  capsule.  A  thin  portion  of  fascia  is  found  inside  the 
veins  between  the  latter  and  the  true  capsule  of  the  prostate.  The  gland  itself  is 
snrrounded  by  a  fibrous  capsule  except  at  the  base,  where  it  adjoins  the  bladder. 

Structure. — It  consists  of  two  lateral  lobes  and  a  middle  lobe.  The  lateral 
lohes  are  developed  as  two  separate  portions  and  in  some  of  the  lower  aninnils 
remain  distinct.     In  man,  they  unite  together  to  form  one  mass.     The  so-called 


66      ANATOMY    OF    THE    URINARY   AND    OENITO-URINARY    TRACT 

middle  lobe  is  merely  the  portion  of  gland  between  the  urethra  and  connnon 
ejaeulatory  duet  and  is  not  marked  off  by  any  distinct  sejjai-ation  from  the 
lateral  lobes.    A  true  middle  lobe  with  a  distinct  line  of  cleavage  is  often  present. 


17  22  15 

Fig.  72. — Sagittal  Section  through  the  Prostate,  a  Little  to  the  Left  of  the  Median  Line. 


Note  the  remains  of  the  ejaeulatory  (common)  duct,  the 
in  this  region.     (Testut.) 

i,  symphysis  pubis. 

2,  bladder. 

2',  neck  of  bladder. 

3,  anterior  bladder  ligament. 

4,  umbilico-prevesical  aponeurosis. 

5,  prevesical  space. 

6,  rectum. 

7,  recto-vesical  space. 

8,  prostate. 

9,  veru  montanum. 

10,  ejaeulatory  duct  on  the  left  side  cut  obliquely. 

11,  vas  deferens  of  right  side. 

12,  inferior  layer  of  triangular  ligament  with  Guthrie' 


vesical  sphincter  and  the  plexuses  of  veins 

IS,  pelvis  fascia  behind  prostate. 

14,  anus. 

15,  15,  external  sphincter. 

16,  Cowper's  gland. 

17,  bulb  of  urethra. 

18,  spongy  portion  of  the  urethra. 

19,  corpora  cavernosa. 

20,  suspensory  ligament  of  the  organ. 

21,  deep  dorsal  vein. 

22,  plexus  of  Santorini. 

23,  perineum. 

24,  scrotum. 
s  muscle. 


The  gland  consists  for  the  gTeater  part  of  muscle  fibers,  that  portion  in  front 
of  the  urethra  being  altogether  muscular.  Elsewhere,  the  glandular  structure 
is  found  imbedded  in  the  muscular  compartments.     This  consists  of  minute 


THE   PENIS 


67 


tubules  lined  with  eolimmar  epithelium.  These  open  hy  about  twenty  ducts 
into  the  urethra  on  either  side  of  the  veru  inontanuni. 

Blood  Supply. — The  prostate  is  supplied  with  blood  by  the  inferior  vesi- 
cal and  inferior  hemorrhoidal  arteries.  The  blood  is  returned  by  the  prostatic 
])lexus  of  veins,  which  empties  into  the  vesical  plexus. 

Lymphatics. — The  lymphatic  return  goes  to  the  iliac  glands. 

Nerves. — The  nerve  supply  of  the  prostate  comes  from  the  hypogastric 
plexus. 

THE   PENIS 

The  penis  consists  of  three  longitudinal  columns  of  erectile  tissue ;  two  of 
tlie  columns,  the  corpora  cavernosa,  much  larger  than  the  third,  are  placed  side 
by  side,  while  the  third  column,  the  corpus  spongiosum,  is  placed  on  the  under 
surface  in  a  groove  between  the  other 
two.  It  is  through  this  portion  that 
the  urethra  passes  (Fig.  Y3). 


Fig.  73. — Penile  Urethra  in  the  State  of 
Repose  and  Erection.    (From  Poirier.) 


1,  cutaneous  layer. 

2,  dorsal  vein,  flanked 
on  each  side  by  dor- 
sal artery  and  nerve. 

3,  tunica  albuginea. 

4,  artery  of  the  corpus 

cavernosum. 


6,  urethra. 

6,  corpus  spongiosum. 

7,  dorsal  vein. 

8,  artery  of  corpus  caver- 

nosum. 

9,  venous  plexus. 


Fig.  74. — Roots  of  the  Penis.      (From  Poirier.) 

1,  the  annular  fibers  of  the  suspensory  ligament. 

2,  pubis. 

3,  the  fibers  of  the  suspensory  ligament  descending 

to  scrotum. 

4,  the  erector  penis  muscle. 

6,  the  bulb  of  the  corpora  spongiosum. 

6,  the  central  fibrous  tendon  of  the  perineum. 


Roots  of  Penis. — The  corpora  cavernosa  arise  from  the  ascending  ramus  of 
the  ischium  on  either  side,  and  are  covered  by  the  ischio-cavcrnosus  muscle 
(Fig.  74).  They  extend  forward  and  inward,  uniting  with  one  another  and  the 
corpus  spongiosum  to  form  the  body  of  the  penis.  The  corpus  spongiosum  at 
its  origin  consists  of  an  expanded  portion  called  the  bulb,  which  is  covered  by 


68     ANATOMY    OF    THE   URINARY    AND    GENITO-URINARY    TRACT 


tlie  ischio-biilbosus  luuscle  and  rests  against  the  triang'ular  ligament,  tlie  middle 
of  the  urogenital  triangle.  This  proceeds  forward  in  the  mid  line  of  the  peri- 
neum to  join  the  corpora  cavernosa.  At  its  distal  extremity  the  corpus  spongi- 
osum becomes  exjianded  and  forms  a  cap  which  fits  over  the  conical  extremities 
of  the  cor]iora  cavernosa.  This  is  known  as  the  glans  penis  (Fig.  75).  It 
slightly  overlaps  the  corpora  cavernosa  and  this  projecting  border  is  known  as 
the  corona  glandis.  At  the  summit  of  the  glans  and  slightly  on  its  under  sur- 
face, is  the  meatus  urinarius  or  external  opening  of  the  urethra   (Fig.   76), 

The  three  columns  of  the  })enis  are 
^,-— ..-■ 's  bound  together  by  fibrous  tissue,  each 

]         \  of  the  jiarts  having  a  separate  cover- 

ing. Between  the  corpora  cavernosa, 
the  fusion  of  this  covering  forms  an 
incomplete  septum — the  septum  pee- 
tiniformie. 


Fig.  75. — Manner  of  Union  of  the  Anterioe 
End  of  the  Corpora  Cavernosa  with  the 
Glans.     (After  Testut.) 

The  anterior  ligament  has  been  cut  through  and 
the  glans  pulled  to  one  side. 

1,  anterior  extremity  of  the  corpus  spongiosum. 

2,  anterior  ligaments. 

3,  urethral  gutter  between  the  corpora  cavernosa. 

4,  5,  glans  with  posterior  capsule. 

6,  the  cleft  in  its  lower  part. 

7,  its  corona. 

8,  corpus  spongiosum  of  the  urethra. 


Fig.  76. — The  End  of  the  Penis. 
(From  Poirier.) 


1,  the  meatus. 

2,  the  frenum. 

3,  fossa  beside  the  fre- 
num. 


4,  the  corona. 

5,  balano-proputial  sul- 

cus. 
G,  prepuce. 


The  penis  is  covered  with  skin, 
which  is  loose  and  freely  movable,  to 
allow  for  expansion  of  the  organ. 
It  is  continued  over  the  glans  as  a 
thin,  firmly  attached  layer,  resembling  mucous  membrane,  and  frequently  de- 
scribed as  such.  From  behind  the  corona  glandis,  a  double  fold  of  delicate  skin 
is  formed  wdiich  covers  over  the  glans  in  the  flaccid  condition  of  the  penis.  This 
is  known  as  the  prepuce,  and  disappears  in  the  erect  condition.  The  skin  over 
the  body  and  glans  then  appears  in  its  true  continuity.  From  just  below  the 
meatus,  a  small  fold  of  skin,  the  frenum  preputii,  passes  to  the  under  surface  of 
the  prepuce.  The  inner  surface  of  the  prepuce  and  posterior  portion  of  the  skin 
over  the  glans  contains  sebaceous  glands  which  secrete  smegma. 


THE    TENIS     •  69 

Suspensory  Ligament. — A  band  of  fibrous  tissue  extends  from  the  symphysis 
[uibis  1(»  the  jienis,  and  is  attached  to  its  fibrous  capsule.  This  is  tlie  suspensory 
liuaiiH'iil-  At  its  attachment  it  separates  into  two  parts  and  through  the  space 
lliiis  tunned  pass  the  dorsal  vessels  and  nerves. 

Structure. — Ivu-h  coluinn  of  the  penis  is  made  up  of  fibrous  covering  con- 
taining many  elastic  libers,  and  within  this  capsule  an  irregular  spongework 
(if  fibrous  trabecuhe  are  formed.  The  interstices  of  the  spongework  consist  of 
lilnod  spaces  lined  by  endothelium  and  empty  directly  into  the  veins.  Hence 
I  lie  size  of  the  organ  is  subject  to  great  variation,  depending  upon  the  amount 
ef  blood  contained  within  this  spongework. 

Blood  Vessels. — The  arterial  supply  comes  from  the  branches  of  the  in- 
ternal pndic;  these  are  the  artery  to  the  bulb,  the  arteries  to  the  corpora  cav- 
ernosa, and  the  dorsal  artery  of  the  penis.  The  glans  is  supplied  by  the 
(l(irsal  artery  which  is  a  continuation  of  the  internal  pudic.  The  veins  empty 
directly  into  the,  prostatic  plexus  or  into  the  dorsal  vein,  which  itself  empties 
into  the  j^rostatic  plexus.  On  the  upper  or  dorsal  surface,  in  a  groove  between 
the  corpora  cavernosa,  the  dorsal  vein  is  situated.  On  either  side  of  the  vein 
are  the  dorsal  arteries  and  just  outside  of  these  are  the  dorsal  nerves. 

Lymphatics, — These  go  to  the  inguinal  glands. 

Nerves. — The  dorsal  nerve  and  superficial  perineal  nerves  from  the  in- 
ternal pudic  nerve  supply  the  skin,  while  the  hypogastric  plexus,  indirectly 
through  the  prostatic  jjlexus,  supplies  the  erectile  tissues. 

In  the  female,  the  clitoris  is  the  analogue  of  the  penis.  It  is  very  small  in 
conijiarison,  and  consists  of  only  two  columns,  the  corpora  cavernosa.  The  bulb 
of  the  vagina  is  the  analogue  of  the  bulb  of  the  penis ;  it  is,  however,  split 
in  two  by  the  jiassage  of  the  vagina,  and  has  a  separate  ischio-bulbosus  muscle 
covering  each  part.  The  bulbs  of  the  vagina  unite  in  front  between  the  urethra 
aud  clitoris  to  form  a  venous  plexus,  which  is  continuous  with  the  glans 
clitoridis. 


CHAPTEK    III 
THE  URINE 

Ik^  treating  of  the  subject  of  urine,  it  is  not  my  intention  to  give  it  the 
comprehensive  and  exhaustive  consideration  demanded  by  a  text-book  on  urine 
analysis.  The  examination  of  the  urine  will  be  gone  into  chiefly  with  reference 
to  its  bearing  on  pathological  conditions  noted  in  genito-urinary  surgery.  I 
shall,  however,  not  lose  sight  of  the  importance  of  so-called  medical  pathological 
conditions,  because  we  find  that  the  kidney  diseases  heretofore  considered 
strictly  within  the  domain  of  medicine  have  begun  to  enter  the  surgical  field. 
Moreover,  in  the  surgical  diseases  of  the  kidney  due  to  pressure,  irritation,  new 
growths  or  pathological  deposits,  an  associated  nephritis  is  wont  to  occur. 

Diseases  of  metabolism  do  not  come  within  the  scope  of  this  work,  except- 
ing so  far  as  they  may  be  considered  associated  with  the  subject  or  must  be  dif- 
ferentiated from  diseases  having  symptoms  in  common  Avith  them. 

We  will  briefly  discuss  the  characteristics  and  the  constituents  of  normal 
urine  before  proceeding  to  take  up  the  various  pathological  changes.  The  card 
used  in  my  laboratory  will  serve  as  a  guide,  as  it  indicates  the  point  of  view 
from  which  we  regard  the  subject.  We  will  give  the  tests  used  in  our  routine 
work  and  mention  the  others  only  by  name,  in  order  that  they  may  be  studied 
in  text-books  on  urinary  analysis,  if  the  reader  desires.  There  are  many  topics 
not  mentioned  on  the  card  that  will  be  spoken  of  and  their  importance  briefly 
considered. 

I.   GENERAL   CONSIDERATIONS 

The  normal  urine  is  a  transparent  fluid  of  an  aqueous  consistency,  of  a  pale 
yellow  color,  with  a  characteristic  odor  and  acid  reaction,  and  a  specific 
gravity  of  from  1.018  to  1.025  at  60°  F.  Few  of  these  characters  are  so  fixed 
that  a  slight  variation  signifies  disease.  The  diet,  the  weather,  the  occupation 
of  the  patient,  may  change  the  features  of  the  urine  within  certain  limits  in 
health.  On  the  other  hand,  great  and  persistent  departure  from  the  above 
standard  usually  means  that  either  the  kidneys  or  the  other  urinary  organs  are 
diseased,  or  that  the  organism  as  a  whole  is  deranged. 
70 


00.00  gms.                   50  oz. 

72.00     ' 

1,110.96  grs. 

0.55    ' 

8.4     " 

0.40    ' 

6.1     " 

0.91     ' 

14.04    " 

10.00    ' 

154.00   " 

2.01     ' 

31.00   " 

3.16    ' 

48.75    " 

7.80    ' 

108.01-123.44    " 

0.77    ' 

11.88    " 

2.50    ' 

38.57   " 

11.09     ' 

171.11    " 

0.26    ' 

4.01    " 

0.21     ' 

3.24    " 

COMPOSITION    AND    PROPERTIES    OF    THE   URINE  71 

II.    COMPOSITION   AND    PROPERTIES    OF   THE   URINE 

The  con.stitiients  of  tlie  urine  are  derived  from  two  sources:  from  the 
cataholism  of  the  tissues  of  the  body  and  from  the  waste  of  ingested  food  and 
liquids. 

The  following"  table  (from  Parkes)  shows  the  composition  of  normal 
urine,  together  with  the  amount  of  each  constituent  excreted  in  twenty -four 
hours : 

Water 1,500.00  gms 

Total  solids 

Uric  acid , 

Hippuric  acid 

Creatinin 

Pigment  and  minor  organic  matters 

Sulphuric  acid 

Phosphoric  acid , 

Chlorine 

Ammonia 

Potassium 

Sodium 

Calcium 

Magnesium 

Selection  of  Specimens  of  Urine  for  Examination.— For  accurate  urinary 
analysis,  either  the  total  amount  of  urine  passed  in  twenty-four  hours  or  a 
sample  ta^en  from  the  entire  quantity,  is  collected  in  a  clean  half-gallon  bottle, 
kept  in  a  cool  place,  well  corked.  In  either  case,  the  quantity  eliminated  in 
twenty-four  hours  should  be  measured.  If  this  is  impossible,  a  four-ounce 
specimen  of  the  night  and  morning  urine  should  be  obtained.  The  urine  passed 
in  the  morning  after  a  night's  rest,  is  least  likely  to  contain  albumin  or  sugar. 
Voided  urine,  if  allowed  to  stand  warm  and  in  an  open  vessel,  becomes  opaque 
in  from  twenty-four  to  forty-eight  hours  by  the  multiplication  of  bacteria,  which 
change  the  urea  to  ammonium  carbonate. 

Preservation  of  Specimen. — ^Urine  should  be  examined  in  as  fresh  a  state 
as  possible.  If  it  has  to  be  kept  more  than  a  few  hours,  some  antiseptic  must 
be  added.  The  best  method  in  the  author's  hands,  has  been  the  addition  of  a 
crystal  or  two  of  thymol.  The  addition  of  an  ounce  of  saturated  solution  of 
boric  acid,  or  two  jS.ve-grain  tablets  of  the  same  to  a  quart  of  urine,  is  preferred 
by  some ;  others  recommend  five  grains  of  salicylic  acid  to  four  ounces  of  urine. 
A  drachm  of  chloroform  to  four  ounces  of  urine  is  also  effective.  Formalin  is 
sometimes  used,  but  cannot  be  recommended,  as  it  interferes  with  the  ex- 
amination. 

Physical  Properties  of  the  Urine. — A:mount  ix  Twexty-four  Hours. — 
The  amount  of  urine  voided  in  twenty-four  hours  by  a  healthy  adult  averages 
from  1,200  to  1,G00  c.c,  the  mean  figure  being  about  1,400,  forty-eight  fluid 


72 


TIIK    URINE 


Laboratory  of  Dr.  Ramon  Guiteras,  80  M 

1 
ADisoN  Ave. 

Urine  of 

Address 

Date 

Report  to  be  sent  to 

Physical  Examination. 

Amount  in  24  hours. 

Spontaneous. 

By  Catheter. 

Color. 

Odor. 

Transparency. 

Reaction. 

Specific  gravity. 

Chemical  Examination. 

Total  solids. 

Albumin. 

Serum.                 Nucleo. 

Quantitative. 

Sugar. 

Fehling  test. 

Quantitative. 

Urea. 

Per  cent. 

Grains  to  ounce. 

Uric  acid. 

Urates. 

Diacetic  acid. 

Aceton. 

Indican. 

Bile  pigment. 

Other  organic 

elements. 

Chlorids. 

Carbonates.                      Phosphates. 

Microscopical  Examination 

Sulphates. 

Amorphous  deposits. 

Crystalline  deposits. 

Red  blood  corpuscles 

Leucocytes. 

Pus.       ■ 

Mucus. 

Tissue.                             Shreds. 

Fat  globules. 

Epithelia. 

Casts. 

Cylindroids. 

Other  elementf 

Microorganisms. 

Diagnosis  from  urine 

analysis. 

Remarks : ' 

'■ 

Fig.  77. — Urine  Analysis  Chart.^ 

ounces,  or  three  pints.  Ronghly  speaking,  the  kidneys  secrete  two  onnces  an 
hour,  that  is,  one  ounce  each.  Children  pass  relatively  larg'er  amounts  than 
adults.  One  kilo  of  the  body  excretes  on  the  average  of  1  c.c.  of  urine  per 
hour.  Women  pass  smaller  quantities  than  men,  on  account  of  their  suuillcr 
average  size.  By  taking  violent  exercise,  by  abstaining  from  drinking  water, 
etc.,  and  by  promoting  free  perspiration,  the  excretion  is  diminished,  but  the 
density  is  increased.  The  amount  is  sometimes  markedly  increased  after  emo- 
tions (joy,  grief,  fright),  and  varies  also  at  different  times  during  the  day. 
The  largest  amount  of  urine  is  usually  passed  in  the  afternoon,  a  moderate 
amount  in  the  forenoon,  and  the  smallest  amount  at  night.  In  warm  weather, 
much  smaller  amounts  are  passed  than  during  the  cold  months. 

Color. — The  color  of  urine  varies  considerably  even  in  health.  The  color 
is  due  to  the  presence  of  urochrome  and  urobilin.  Diluted  urines  are  usually 
pale ;  concentrated  urines  are  dark.     The  color  may  be  changed  by  drugs,  the 


^  The  accompanying  charts  are  used  by  the  author  in  recording  urinarj^  examinations.     They 
may  be  kept  printed  in  blank  form,  as  illustrated,  and  filed  with  the  history  of  the  case. 


COMPOSITION    AND    PllOPERTIES    OF    THE   URINE  73 

amount  of  water  drunk  and  tlie  other  factors  influencing  quantity,  and  some- 
times by  the  quality  of  the  food. 

The  color  of  the  urine  is  markedly  pale  and  forms  a  diagnostic  feature  in 
chronic  interstitial  nephritis,  diabetes  mellitus  and  insipidus. 

In  acute  fevers  and  in  congestion  of  the  kidneys  it  is  highly  colored,  due  to 
concentration  of  the  urine.  A  dark  brownish-red  color  is  often  characteristic 
of  heniorrhage  from  the  kidney.  Hemorrhage  from  the  bladder  or  ureters  gives 
the  urine  a  bright-red  color. 

Odok. — The  odor  of  the  urine  is  characteristic  and  cannot  be  compared  with 
any  other.  Certain  variations  from  the  normal  are  significant  of  disease.  If 
freshly  voided  urine  is  putrid  or  ammoniacal,  there  must  have  been  decompo- 
sition in  the  bladder  or  above  this  organ,  as  is  often  the  case  in  pyelitis  and 
cystitis. 

When  large  quantities  of  pus  are  present,  the  odor  is  sulphuretted,  owing 
to  the  decomposition  of  the  albuminous  substances.  In  diabetes  mellitus,  the 
urine  usually  has  a  peculiar  aromatic  odor.  Certain  foods  and  drugs,  such  as 
asparagus,  garlic,  the  balsams  of  copaiba  and  Peru,  turpentine,  saffron,  etc., 
impart  easily  distinguishable  odors  to  the  urine. 

Teansparency. — Normal  urine,  freshly  voided,  is  always  perfectly  trans- 
parent. On  standing  a  few  minutes,  a  faint  cloud  often  appears,  known  as 
the  nubecula,  which  floats  in  the  center  or  sinks  to  the  bottom.  It  consists  of 
mucus,  bacteria  and  epithelial  debris.  In  w^omen,  vaginal  mucus  is  mixed  with 
the  urine  and  may  cloud  it  considerably ;  and  in  catarrhal  and  other  inflam- 
matory conditions  of  the  genito-urinary  tract,  the  normal  mucous  cloud  may 
also  be  increased.  The  urine  is  then  cloudy  from  the  first  on  being  voided. 
The  normal  mucous  cloud  is  distinct  from  other  causes  of  turbidity  to  be 
mentioned. 

Cloudiness  in  urine  may  result  from  (1)  bacteria,  (2)  phosphates,  (3) 
urates,  (4)  j)us,  and  (5)  fat.  The  following  table  shows  the  shortest  methods 
of  differentiating  the  causes  of  cloudiness  by  means  of  simple  reagents. 

Differentiation  of  the  Principal  Causes  of  Turhidity  in  the  Urine. 

( 1 )  Heat  the  urine  for  a  few  seconds : 

(a)  Turbidity  increases  or  precipitate  forms:  bacteria^  mucus,  phosphates 
or  pus. 

{{))   Turbidity  disappears:  urates. 

(2)  Add  acetic  acid : 

(fl)   Turbidity  unchanged:  bacteria,  urates. 

(b)  Turbidity  increased  or  preci})itates :  mucus  or  pus,  or  both. 
(/•)   Dispelled  at  once:  phosphates. 

(3)  Add  potassium  hydrate: 

(a)  Turbidity  or  precipitate  disappears:  urates. 

(b)  Is  changed  to  a  gelatinous  eoagulum  :  pus. 


74 


THE   URTNE 


Reaction. — In  herbivora,  the  urine  is  alkaline;  in  carnivora,  acid.  Tn 
man,  on  a  mixed  diet,  it  is  normally  acid.  The  acidity  depends  npon  the  food 
ingested  and  is  due  chiefly  to  the  presence  of  acid  sodium  phosphate  and  hip- 
pnric  acid.  The  acidity  varies  at  different  times  of  the  day  in  regular  sequence ; 
diminishing  soon  after  meals,  it  changes  in  about  three  or  four  hours,  when  the 
urine  may  become  alkaline.  Alkaline  salts  or  vegetable  acids  in  tlie  food  in- 
crease the  alkalinity,  the  acids  being  converted  into  carbonates  (alkaline  salts) 
in  the  blood.  An  excess  of  meat  in  the  diet  will  increase  the  acidity,  while  a 
vegetarian  diet  produces  alkalinity. 

The  acidity  is  tested  by  means  of  red  and  blue  litmus  paper ;  the  blue  tunis 
red  in  acid  urine ;  the  red  turns  blue  in  alkaline  urine. 

Specific  Gravity. — The  specific  gravity  of  normal  urine  is  between  1.012 
and  1.024;  the  standard  normal  average  1.020  at  60°  F.  It  varies  in  health, 
according  to  the  time  of  day,  the  meals  and  the  amount  of  exercise,  the  amount 
of  fluid  drunk  and  the  total  amount  of  urine  passed  daily,  as  well  as  the  amount 
of  solids  excreted.  Therefore,  to  measure  specific  gravity  accurately,  allowances 
must  be  made  for  the  conditions  of  diet,  exercise,  etc. 

The'  specific  gravity  of  urine  is  increased  by  an  excess  of  nitrogenous 
food,  by  sweating  and  muscular  exertion.  A  lower  specific  gravity  with 
absence  of  albumin  or  sugar,  means  less  urea ;  it  also  means  an  increased 
quantity  of  urine,  except  in  heart  disease  and  in  the  last  stages  of  chronic 
Bright's  disease,  when  combined  low  quantity  and  specific  gravity  is  a  grave 
sign. 

Determination. — The  specific  gravity  is  best  determined  by  means  of  a 
special  hydrometer,  known  as  a  urinometer.  (See  Fig.  78.)  Before  testing, 
the  urine  should  be  allowed  to  cool  to  room  temperature,  for  when  just  voided, 

it  has  about  the  temperature  of  the  body.  A  suffi- 
cient amount  of  urine  is  filtered  into  the  cylinder 
accompanying  each  instrument,  and  the  uri- 
nometer, carefully  cleaned  and  aired,  should  be 
innnersed  gently  with  a  slight  spinning  turn, 
which  prevents  its  adhesion  to  the  sides  of  the 
vessel.  Any  foam  on  the  surface  of  the  urine 
may  be  removed  by  means  of  filter  paper.  To 
read  the  urinometer,  we  must  read  the  line  at 
the  level  of  the  lower  portion  of  the  meniscus, 
formed  at  the  contact  of  the  urine  with  the  stem. 
An  instrument  for  the  estimation  of  the 
specific  gravity  of  about  3  c.c.  of  urine  with  clin- 
ical accuracy,  was  devised  by  De  Santos  Saxe 
while  working  in  my  laboratory,  principally  with  the  object  of  estimating 
specimens  of  urine  taken  from  the  kidney  by  the  ureteral  catheter.     It  is  known 


u 


Fig.  78.  —  Squibbs  Urinometer, 
WITH  Thermometer  and  Cyl- 
inder. 


COMPOSITION    AND    PKOPERTIES    OF    THE    URINE 


75 


as  the  pykiiometov.^      This  consists  of  a  flask  with  a  well-fitting  glass  stopper, 

the  head  of  whicli  bears  a  small  bead  of  mercury.     (See  Fig.  79.)     This  flask  is 

fixed  to  one  pole  of  a  small  spheric  bulb,  to  the  other  pole  of 

which  is  attached  the  stem  of  the  instrument.     The  mark  1,060 

is  at  the  toj)  of  the  stem,  and  the  mark  1,000  at  the  bottom,  so 

tliat  the  instrument  is  graduated  in  reverse  order  as  compared  to 

tlic  ordinary  hydrometer.     When  the  flask  is  filled  with  distilled 

water  up  to  the  nuirk  "  M  "  and  when  the  instrument  is 

closed   and   immersed   in  distilled  water,   it  reads   at 

1,000.     When  urine  is  poured  into  the  flask  instead  of 

distilled  water  up  to  the  same  mark,  the  instrument 

sinks  in  distilled  water   in  proportion  to   the   specific 

gravity  of  the  urine,  which  is  then  read  on  the  scale  in 

tiie  same  way  as  the  ordinary  urinometer. 

Total  Solids. — The  amount  of  total  solids  in 
the  twenty-four  hours'  urine  determines  the  specific 
gravity.  The  specific  gravity,  as  a  rule,  varies  in  pro- 
portion to  the  amount  of  solids,  but  in  certain  diseases 
the  watery  element  of  the  urine  predominates,  without 


any  marked  change  in  the   amount   of  solids   in  the 


Fig.  79. — Saxe's  Urinopyk- 
nometer  and  cylinder. 
(Eimer  &  Amend.) 


t\\'cnty-four  hours'  specimen. 

For  clinical  purposes,  the  amount  of  total  solids  in 
the  twenty-four  hours'  normal  urine  can  be  determined 

approximately  by  multiplying  the  last  two  figures  of  the  specific  gravity  by 
Haeser's  coefficient,  which  is  2.33,  and  thus  obtaining  roughly  the  number  of 
grams  of  solids  in  1,000  c.c.  (1  liter)  of  urine.  This  number,  multiplied  by 
the  number  of  c.c.  passed  in  twenty-four  hours  and  divided  by  1,000,  gives  in 
grams  the  amount  of  solids  eliminated  in  twenty-four  hours. 

A  much  more  accurate  method  of  determining  the  amount  of  solids  is  to 
evaporate  a  given  amount  of  urine  in  a  previously  weighed  porcelain  dish,  dry- 
ing the  residue,  cooling  and  weighing  repeatedly  until  there  is  no  further 
loss  of  weight  from  drying. 

The  average  amount  of  excretion  in  twenty-four  hours  by  a  person  weighing 
145  pounds  (60  kilos),  is  945  grains  (61.25  grams).  This  applies  to  an 
ordinary  diet  of  mixed  food  and  to  a  healthy  man  taking  ordinary  exercise. 
Olio  third  should  be  deducted  for  persons  who  have  fasted  for  two  days  or 
longer;  one  eighth  if  the  diet  be  spare;  one  tenth  for  perfect  rest;  one  twen- 
tieth for  comparative  rest.  According  to  Parkes,  the  amount  of  solids  ex- 
crL'ted  begins  to  diminish  after  forty  and  sinks  to  fifty  per  cent  of  the  normal 
above  seventy  years  of  age. 


*  Made  by  Eimcr  &  Amciul,  New  York  Cit}', 


76  THE   URINE 

III.    CHEMICAL   EXAMINATION    OF   THE   URINE 

The  Proteids 

The  jiroteids  found  in  the  urine  under  various  conditions  are: 
Serum  albumin.  Fibrin. 

Nucleo-albumin.  Albnmose. 

Serum  globulin.  Peptone. 

Albumin 

Serum  albumin  is  the  most  important  abnormal  proteid  found  in  tlie  urine. 
Albuminnria  has  reference  to  the  presence  of  serum  albumin  of  the  blood  in 
the  nrine,  and  serum  albumin  is  usually  significant  of  deranged  renal  function 
or  pathological  changes  in  the  kidney.  Serum  albumin  is  occasionally  found 
in  certain  individuals  under  apparently  perfect  normal  conditions.  Traces 
may  also  appear  in  healthy  individuals  after  excessive  exercise,  overindul- 
gence in  meats  or  a  diet  of  eggs. 

Nudeo-albumin  is  a  compound  of  a  proteid  and  nuclein  contained  in  cell 
protoplasm.  In  the  urine  it  is  derived  from  the  nuclei  of  epithelial  cells  and 
leucocytes.  The  organic  debris  of  normal  urine  includes  more  or  less  of  this 
cellular  element  and  consequently  it  is  possible  by  delicate  tests  to  detect 
minute  traces  of  nucleo-albumin  in  normal  urine.  In  inflammatory  condi- 
tions of  the .  nrinary  tract  where  there  is  considerable  amount  of  pus  and 
epithelium  present,  nucleo-albumin  is  abundant.  Where  this  is  the  case  and 
when  at  the  same  time  the  urine  is  to  be  examined  for  possible  evidence  of 
kidney  derangement  or  disease,  it  becomes  very  important  to  differentiate  the 
serum  albumin  from  the  nucleo-albumin.  Under  the  tests  for  albumin,  a 
method  of  procedure  will  be  given. 

Qualitative  Tests  for  Albumin. — Xitric-Acid  Test  {Heller's). — Pour  a 
small  quantity  (5  to  10  c.c.)  of  nitric  acid  in  a  test-tube.  Hold  the  tube  in 
a  slanting  position  and  with  a  pipette  allow  about  an  equal  amount  of  filtered 
urine  to  slowly  trickle  down  on  top  of  the  acid.  If  albumin  is  present,  a  white 
line  appears  at  the  junction  of  the  two  liquids.  If  the  amount  present  is  large, 
there  is  at  once  a  wide  band  formed.  This  test  is  quite  sufiicient  for  ordinary 
purposes.  It  is  not  only  reliable  in  determining  the  presence  or  absence  of 
albumin,  but  it  also  gives  evidence  as  to  the  })resence  of  other  proi^erties, 
to  wit : 

Excess  of  indican :  purple  band. 

Bile  pignnent :  green  band. 

Uric  acid:  faint  leaving  ring  above  the  juncture  of  tlie  liijuids. 

Mucin :  a  cloudy  band  still  higher  up  above  the  acid. 

Should  the  above  test  aive  doubtful  reactions,  the  followinu'  sensitive  tests 
can  be  employed. 


CHEMICAL   EXAMINATION   OF    THE   URINE 


77 


Potassium-Ferkocyanid  Test. — To  a  test-tube  of  filtered  urine  add  five 
to  ten  drn]is  of  acetic  acid  and  a  few  drops  of  a  ten-per-cent  ferrocyanid-of- 
potassiiiiii  solution.  If  :ill)innin  is  present,  a  cloudiness  will  at  once  appear. 
Very  delicate  in  doubtful  cases. 

Tki('iilo]{acetic-Acii)  Test. — This  is  one  of  tlie  most  delicate  tests  known. 
It  is  often  possible  to  demonstrate  minute  traces  of  albumin,  with  this  test, 
in  urines  containing'  a  few  casts  when  the  common  tests  fail  to  show  any  reac- 
tion. To  a  test-tube  containing  the  filtered  urine,  add  with  a  pipette  1  or  2  c.c. 
of  a  solution  of  trichloracetic  acid,  depositing  the  reagent  carefully  at  the 
bottom  of  the  tube  beneath  the  urine.  (Specific  gravity  of  the  reagent  equals 
1.147.)  A  white  zone  at  once  forms  at  the  junction  of  the  two  liquids  if  albu- 
min is  present.  Albumose  and  excess  of  uric  acid  also  show  a  reaction,  but  the 
former  disappears  on  boiling  and  the  latter  on  heating. 

SERu^ii-ALBUMiN  Test.- — Reference  has  already  been  made  to  the  fact  that, 
in  genito-urinary  work,  it  becomes  necessary  frequently  to  differentiate  the 
micleo-  from  the  serum-albumin.  This  can  be  done  very  readily  by  the  following 
method : 

''  Xucleo-albumin  is  not  precipitated  by  heat  and   acid   in  highly   salted 
urines.     To  prove  serum  albumin,  therefore,  to  the  urine  add  one  fifth  volume 
of  saturated  sodium-chlorid  solution,  heat  the  upper  one  third, 
add  two  to  five  drops  of  fifty-per-cent  acetic  acid,  heat  a  second 
time.     A  jJersistent  cloud  equals  serum  albumin."  ^ 

Quantitative  Estimation  of  Albumin. — The  absolutely  ac- 
curate quantitative  methods  of  testing  for  albumin  are  entirely 
too  elaborate  for  clinical  work.  They  will  be  found  described 
in  the  handbooks  on  urinary  analysis. 

EsBACii's  Method. — This  is  a  convenient  method  of  quan- 
titative estimation,  which  is  sufficiently  accurate  for  clinical 
purposes.  The  apparatus  is  a  graduated  glass  tube  ( albu- 
uiinometer.  Fig.  80)  which  is  filled  with  urine  to  the  letter 
"  U."  Esbach's  reagent  is  added  up  to  the  mark  "  R."  (This 
reagent  consists  of  picric  acid,  ten  parts ;  citric  acid,  twenty 
parts;  and  distilled  water,  one  thousand  parts.) 

The  tube  is  closed  with  a  rubber  stopper  and  the  contents 
mixed  by  inverting  it  several  times.  The  number  at  the  level 
of  the  precipitate,  read  after  allowing  the  tube  to  stand  for 
twenty-four  hours,  shows  the  number  of  gTams  of  albumin 
contained  in  one  liter  of  urine.  Each  gram  represents  one 
tenth  of  one  per  cent  by  weight.  When  large  quantities  of  albumin  are 
present    {ovev  0.7   per  cent,   the  highest  mark  on  the   scale),   the   urine  must 


Fig.  80. —  Esbach's 
Albuminometer. 


'  Hastings,  New  York  Medical  Journal,  July  7,  1906. 


78  THE    URINK 

1)C'    diluted    with    t'(|ii:d    parts    of    distilled    water,    and    the    results    niidtiplied 
by  two. 

This  method  is  not  absolutely  accurate  for  the  reason  that  ])icric  acid  also 
precipitates  urates,  jieptone  and  vegetable  alkaloids. 

Serum  Globulin 

Serum  globulin  is  nearly  alwa^'s  present  together  with  serum  all)umin,  and 
usually  it  is  not  necessary  to  differentiate  them.  Excess  of  globulin,  however, 
as  compared  to  the  amount  of  albumin,  is  noted  in  catarrhal  cystitis,  in  acute 
nephritis,  and  particularly  in  amyloid  degeneration  of  the  kidney.  In  chronic 
nephritis,  globulin  is  scant  or  even  absent. 

Tests  for  Globulin. — The  urine  is  accurately  neutralized  by  adding  alkali 
or  acid,  as  the  case  may  be ;  is  filtered  and  is  completely  saturated  with 
magnesium  sulphate  at  ordinary  temperature,  a  white  precipitate  immedi- 
ately forming  with  globulins.  If  this  precipitate  be  filtered  off,  the  same 
urine  may  be  tested  for  serum  albumin  by  heating  wath  a  few  drops  of  acetic 
acid. 

Fibrin 

Fibrin  is  an  elastic,  white,  stringy  albuminous  substance,  insoluble  in  water 
and  alcohol.  It  is  soluble  in  solutions  of  magnesium  sulphate,  with  the  forma- 
tion of  globulin,  and  by  the  addition  of  strong  acid  it  is  converted  into  acid 
albumin.  When  found  in  the  urine,  fibrin  means  the  presence  of  blood.  A 
urine  containing  fibrin  may  coagulate  spontaneously  on  standing.  It  is  im- 
portant to  distinguish  between  fibrin  and  the  gelatinous  mass  formed  by  pus. 
The  nature  of  the  clot  can  be  determined  chemically  by  Millon's  reagent,  but 
the  point  can  be  settled  much  quicker  by  a  microscopical  examination. 

Alhumose 

Albumose  is  an  intermediate  product  between  the  original  proteid  (albu- 
min) and  the  final  products  of  digestion  (peptone).  Albumose  is  not  coagu- 
lable  by  heat ;  is  precipitated  but  not  coagulated  by  alcohol.  It  is  precipitated 
by  nitric  acid,  the  precipitate  thus  formed  being  temporarily  dispelled  by  heat. 
It  does  not  usually  occur  in  ordinary  albuminuria.  It  occurs  in  the  urine  in 
febrile  diseases  and  in  septic  conditions,  such  as  empyema,  in  intestinal  ulcers, 
and  ulcerating  maligTiant  gTowths. 

There  is  a  very  rare  form  of  albuminuria  which  occurs  only  in  myelo- 
sarcoma of  the  bones  and  is  often  spoken  of  as  Bence-Jones  albuminuria. 


CHEMICAL   EXAMINATION    OF    THE   URINE  79 

Mucus 

A  small  ainoniit  of  nniciis  is  present  in  normal  nrine.  Under  the  microscope 
tliis  nmcus  is  seen  to  be  composed  of  mncons  threads — trans])arent,  homogenous, 
stringy  masses.  Mncns  is  a  normal  product  of  epithelial  cells  and  is,  therefore, 
always  found  in  the  nrine.  An  increase  in  the  normal  amount  of  mucus  is  one 
of  the  hrst  evidences  of  irritation  somewhere  along  the  urinary  tract.  This 
uiav  be  due  to  highly  acid  or  highly  concentrated  urine,  or  to  the  presence  of 
irritating  crystals. 

Mucin 

Mucin  is  the  chemical  basis  of  mucus  and  forms  the  gTeat  bulk  of  the  so- 
called  nubecula  or  mucous  cloud  occurring  in  normal  urine.  The  amount  of 
mucin  is  greatly  increased  in  pathological  urines,  owing  to  the  presence  of  irri- 
tation of  the  surface  of  some  part  of  the  genito-urinary  tract.  Mucin  is  pre- 
cijntated  by  acetic  acid  and  is  distinguished  from  nucleo-albumin  in  that  it  is 
soluble  in  a  slight  excess  of  the  acid.  The  presence  of  mucin  does  not  inter- 
fere with  the  ordinary  albumin  test,  as  it  is  dissolved  in  an  excess  of  Esbach's 
and  other  reagents. 

Carbohydrates 
Glucose 

The  occurrence  of  sugar  in  the  urine  is  especially  of  interest  to  the  urolo- 
gist, on  account  of  its  association  with  polyuria  and  may,  therefore,  be  a  cause 
of  frequency  of  urination.  The  j)olyuria  may  have  escaped  the  patient's  notice, 
because  people  voiding  their  urine  in  urinals  and  closets  are  not  aware  of  how 
much  they  are  passing  each  time._  It  is,  therefore,  important  to  include  sugar 
tests  as  a  matter  of  routine  in  every  urine  examination. 

Qualitative  Tests  for  Sugar. — Fehling's  Test. — The  reagent  consists  of 
two  parts  which  must  be  kept  in  sej)arate  bottles,  in  a  dark  place : 

I.    Copper  Solution   (Tyson) 

Copper  sulphate 34.652  gin. 

Distilled  water 500  c.c. 


II.    Alkaline  Solution   (Tyson) 

Sodium  potassium  tartrate  (Rochelle  salt)    175  gm. 

Sodium  hydrate  solution  (specific  gravity  1.120)    ....    480  c.c. 
Distilled  water,  enough  to  make 500  c.c. 


80 


TTTF,    rUTXE 


(The  sodium  liydratc  sidiitioii  contains  r)2.72T  gin.  of  caustic  soda  and 
enough  distiHed  watci-  to  make  HOO  c.e. ) 

In  testing  for  sugar,  dilurc  1  cc.  of  each  of  these  solutions  in  about  for.r 
times  the  amount  of  water  and  l)oi]  the  mixture  for  a  few  seconds.  If  the  solu- 
tion becomes  clouded  on  boilinu',  tlio  reagents  should  bo  freshly  prepared.  If 
the  solution  remains  clear,  the  sus]x^('tcd  urine  should  be  added  drop  by  drop. 
If  sugar  is  present  in  considerable  amount,  the  hrst  two  dr(tps  will  cause  a 
yellow  or  red  precipitate  of  copper  suboxid. 

One  should  continue  to  add  the  urine  until  an  anir)unt  has  been  added  e(pud 
to  the  reagent,  and  then  boil  it.  If  no  precipitate  occurs  within  thirty  minutes, 
allow  the  tube  to  stand  for  a  day  for  possible  traces  of  sugar. 


Fig.  81. — The  Laurent  Penumbra  Pol.arizing  Saccharometer.     (From  Tyson.) 


An  improved  solution  consists  of  thirty  gTains  of  copper  sulphate,  half  an 
ounce  of  distilled  water,  half  an  ounce  of  pure  glycerin,  and  live  ounces  of 
potassium-hydrate  solution.  Boil  a  dram  of  this  solution  in  a  test-tube,  and 
add  eight  drops  of  the  urine.  Boil  the  mixture  gently,  and  if  sugar  is  present, 
a  yellow  or  yellowdsh-red  precipitate  appears. 

ISTylander's  Test. — This  test  reveals  sugar  in  amounts  of  0.1  per  cent  or 
over  and  can  be  strongly  recommended  for  the  use  of  the  practitioner.  It  is 
easily  performed  and  the  solution  keeps  perfectly  for  many  months.  The  solu- 
tion is  composed  of  bismuth  subnitrate,  2  parts ;  Rochelle  salts,  4  parts ;  sodium 


CHElvnCAL   EXAMINATION   OF    THE   URINE  81 

hydrate  (sticks),  8  i:)arts ;  water,  100  parts.  One  part  of  this  solution  is  added 
t(»  !)  ])arts  by  volume  of  the  urine  and  the  mixture  boiled  in  a  test-tube  for  one 
or  two  laiuutes.  The  reaction  begins  as  a  grayi.sh-ldack  coloration  which  HO(jn 
becomes  deep  black. 

PoLARiMETRY  is  a  Convenient  and  quick  method  for  the  quantitative  deter- 
in  ination  of  glucose  when  it  exceeds  0.5  per  cent.  The  urine  must  be  clarified 
l)i'f()re  testing.  The  test  depends  on  the  fact  that  glucose  rotates  polarized  liiiht 
to  the  right,  and  the  proportion  of  sugar  in  solution  is  determined  by  the  de- 
gree of  deviation  noted.  The  polariscope  of  Laurent,  made  by  Schmidt  & 
Ilaench,  of  Berlin,  is  probably  the  most  useful   (Fig.  81). 

Pheis^yl-Hydrazix  Test  (Williamson  s  Method).- — Fill  a  test-tube  of  or- 
dinary size  for  about  half  an  inch  with  powdered  phenyl-hydrazin  hydro- 
cldorate ;  then  add  another  half  inch  of  powdered  sodium  acetate.  Fill  half  the 
test-tube  with  urine,  and  boil  it  over  a  spirit  lamp  for  about  two  minutes.  The 
powders  dissolve  and  the  tube  is  allowed  to  stand  to  deposit  a  yellow  sediment. 
This,  under  a  microscope,  is  seen  to  consist  of  bright  yellow  needle-shaped  crys- 
tals arranged  in  sunburst  fashion  (phenyl-glucosazone).  They  are  almost  in- 
soluble in  water,  but  dissolve  in  boiling  alcohol. 

Precautioxs  IX  Testixg  for  Sugar. — In  testing  for  sugar,  all  utensils 
must  be  perfectly  clean,  and  albumin  must  be  removed  if  present  in  any  con- 
siderable quantities.  In  using  the  copper  test,  always  add  to  the  boiling  solu- 
tion as  few  drops  of  the  urine  as  possible,  waiting  a  moment  or  two  before 
adding  a  few  more  drops,  and  so  on,  until  equal  parts  of  the  reagent  and  the 
urine  are  used.  If  the  urine  is  boiled  with  a  copper  solution,  there  may  be  a 
gTeenish  color,  or  a  greenish  opacity,  or  even  a  brownish  color  without  the 
presence  of  sugar.  An  excess  of  copper  sulphate  or  too  strong  a  solution  should 
not  be  used,  because  they  g-ive  rise  to  these  precipitates  without  any  sugar. 

Quantitative  Tests  for  Sugar. — Fermentation  Test. — By  fermenting 
urine  with  yeast,  the  sugar  is  decomposed  into  alcohol,  cai'ljnu  dioxid,  etc.,  with 
a  decrease  in  the  specific  gTavity  of  the  urine.  Each  degree  lost  is  equivalent 
to  one  gTain  of  sugar  to  the  ounce  of  urine. 

Robert's  Method. — Into  a  twelve-ounce  flask,  put  four  ounces  of  urine 
and  a  small  lump  of  yeast ;  cork  the  bottle  with  a  nicked  cork  to  allow  the 
carbon  dioxid  to  escape ;  set  it  aside  in  a  warm  place  to  ferment.  With  it,  put  a 
tightly  corked  four-ounce  flask  of  the  same  urine  without  yeast,  for  comparison. 
After  eighteen  to  twenty-four  hours,  the  fermented  urine  is  decanted  aiid  the 
specific  gravity  noted.  At  the  same  time  the  specific  gTavity  of  the  unfer- 
mented  urine  is  taken.  The  former  subtracted  from  the  latter  shows  the  de- 
gree of  gravity  lost,  which  may  be  read  at  once  as  gTains  of  sugar  per  ounce. 
Or  else,  the  number  of  the  lost  degrees  may  be  multiplied  by  0.23  to  obtain 
the  percentage.  The  chief  objection  to  this  method  is  that  it  requires  too 
much  time. 


82 


THE    URIXE 


Lohnstein's  sacciiaeometer  (Fig.  82)  is  a  very  accurate  fermentation 
apparatus  devised  for  uriues  containing  large  quantities  of  sugar.  It  is  pro- 
vided with  a  scale  graduated  for 
sugar  percentages  at  two  different 
temperatures  and  is  so  constructed 
that  the  fermenting  urine  is  separated 
from  the  outside  air  by  a  column  of 
mercury.  It  thus  avoids  the  errors 
made  in  the  use  of  the  Einhorn  sac- 
charometer  at  widely  differing  tem- 
peratures. 

Einhoen's  sacciiaeometer  (Fig. 
83)  is  used  in  sets  of  two,  one  being 


Fig.  82. — Lohnstein's  Saccharometer  for 
Undiluted  Urine.     (From  Wood.) 


Fig.  83.- 


-Einhorn's  Saccharometer. 
(From  Wood.) 


filled  with  normal  urine  for  comparison.  A  small  piece  of  fresh  yeast  is  mixed 
thoroughly  with  a  definite  quantity  of  the  suspected  urine  measured  in  a  marked 
test-tube  that  comes  with  the  apparatus.  The  mixture  is  then  poured  carefully 
into  the  graduated  tube,  care  being  taken  to  expel  all  the  air  by  slanting  the 
tube  so  that  bubbles  escape.  The  tubes  are  allowed  to  stand  at  a  temperature 
of  about  86°  F.  until  fermentation  has  ceased,  i.  e.,  for  about  twenty-four  hours. 
The  CO2  resulting  from  fermentation  collects  at  the  top  of  the  tube,  and  the 
percentage  of  sugar  is  read  off  at  the  level  of  the  fluid.  If  the  second  tube  also 
shows  a  small  amount  of  gas,  this  is  deducted. 


CHEMICAL    EXAMINATION    OF    THE    UKINE  83 

The  above  are  the  principal  tests  for  sugar  employed  in  clinical  work.  For 
the  other  methods,  the  reader  is  referred  to  the  larger  handbooks. 

Other  Cai'boJiydrates 

Three  other  carbohydrates  are  sometimes  found  in  the  nrinc,  Imt  arc  of 
very  slight  clinical  importance.  They  are  lactose  or  milk  sugar,  laivulose  or 
fruit  sngar,  and  inosite,  or  muscle  sugar.  The  isolation  of  these  requires  elabo- 
rate apparatus,  and  the  use  of  the  polariscope.  Lactose,  however,  gives  the 
])hcnyl-liydrazin  test,  forming  yellow  needles  grouped  in  clusters. 

Urea  and  its  Compounds 
Urea 

The  most  important  element  in  the  urine  is  urea,  representing,  as  it  does, 
the  last  term  in  the  series  of  oxidized  nitrogenous  bodies.  Its  source  is  two- 
fold :  from  the  tissue  waste  and  from  ingested  food.  The  greater  part  of  nitro- 
gen in  food  appears  in  the  urine  in  the  form  of  urea,  wdiicli  ranges  from  three 
hundred  to  six  hundred  grains  in  twenty-four  hours  (20-40  grams  or  1.5  to  2.5 
per  cent).  The  average  daily  amount  of  urea  for  a  healthy  man  on  a  mixed 
diet  with  moderate  exercise  may  be  estimated  as  33.8  grams,  which  gives  about 
0.015  to  0.035  grams  per  hour  for  each  kilogram  of  body  weight.  Women  and 
children  excrete  a  less  quantity  of  urea  than  men,  but  relatively  more  per  pound 
of  body  ^veight.  The  normal  standard  urea  excretion  generally  accepted  in 
clinical  work  is  two  per  cent,  or  twenty  grams  per  liter,  or  ten  grains  to  the 
ounce. 

The  organs  chiefly  concerned  in  the  production  of  urea  are  the  liver  and 
tlic  spleen,  but  lymph  nodes  probably  assist  to  a  slight  extent.  The  maximum 
(piantity  of  urea  occurs  with  meat  diet  and  the  minimum  with  a  vegetable  diet. 
Changes  in  the  daily  amount  of  excreted  urea  correspond  so  closely  to  the  de- 
struction of  tissue  and  the  assimilation  of  proteids  that  they  form  a  valuable 
index  of  bodily  health.  In  fevers  and  inflammations,  in  the  waking  state  and 
under  intense  muscular  or  mental  work,  urea  is  markedly  increased  in  the  daily 
amount  eliminated ;  in  liver  and  kidney  disease,  in  several  of  the  cachexias,  it 
is  diminislied. 

Quantitative  Estimation  of  Urea. — There  are  many  elaborate  methods  for 
accurately  ascertaining  •  the  amount  of  urea.  The  most  available  method  in 
the  clinical  laboratory  is  the  one  that  is  based  on  the  fact  that  urea  is  decom- 
posed into  carbon  dioxid  and  nitrogen  in  the  presence  of  sodium  hypobromite. 

The  reagents  are  most  conveniently  kept  and  apjdied  in  the  form  of  Rice's 
solutions:  (1)  caustic  soda  100  grams,  distilled  water  250  grams;  (2)  broniiu 
30  grams,  potassium  bromid  30  grams,  water  240  grams. 


84 


THE    URTXE 


The  test  is  made  in  Doromus's  iireometer,  or  in  one  of  the  numerous  modi- 
fications of  it. 

DoREMUs's    Ureometer    (Figs.    84    and    85). — This    apparatus    consists 
of  a  bulb   witli  an   ii])rii:lit    m'adiiatcd   tube  and   a  small  nipple  pipette,  hold- 
ing   1    c.c.    of    urine.     The    gradua- 
tions   read    in    fractions    of    a    gram 
of    urea    per    c.c.    of    urine,    or    else 


Fig.  84. — Doremus  Ureometer. 


Fig.  85.- 


-DoREMUS  Ureometer,  Improved  Form. 
(From  Wood.) 


show  the  number  of  grains  of  urea  per  fluid  ounce  of  urine.  The  bulb  is 
filled  with  the  hypobromite  solution  (one  of  the  formulic  given  aljove),  and 
the  tube  is  inclined  so  as  to  remove  the  last  air  bubble  from  its  closed  part. 
One  c.c.  of  urine  is  then  taken  with  the  pipette,  and  the  point  of  the  latter  is 
introduced  into  the  bend  of  the  tube.  The  nipple  is  slowly  and  gently  com- 
pressed, care  being  taken  to  expel  all  the  urine,  but  not  to  drive  any  air  out 
of  the  nipple.  The  pipette  should  be  dried  before  being  introduced,  and  should 
be  filled  accurately.  The  sodium  hypobromite  in  the  solution  qomes  into  con- 
tact with  the  urea  of  the  urine,  which  is  decomposed  into  nitrogen,  carbon 
dioxid  and  water.  The  amount  of  nitrogen  disengaged  is  a  measure  of  the 
urea,  and  1  c.c.  of  nitrogen  at  standard  temperature  and  pressure  equals  0.0027 
grams  of  urea.  The  gas  is,  therefore,  allowed  to  escape  into  the  top  of  the  tube 
and  the  level  of  the  fluid  to  sink  until  no  more  bubbles  escape.  This  takes  ten 
or  fifteen  minutes  or  sometimes  longer.  The  percentage  of  urea  is  then  simply 
read  on  the  graduated  tube. 


Uric  Acid 

Uric  acid  is  a  nitrogenous  compound  occurring  in  the  urine  in  daily  amounts 
from  0.4  to  0.8  grams.  It  is  formed  in  the  body  by  the  decomposition  of  the 
nucleins  of  the  nuclei  of  the  cells  of  both  food  and  tissues.     It  is  freely  soluble 


CHEMICAL   EXAMINATION   OF    THE   URINE 


85 


in  water,  especially  Avitli  heat,  and  is  still  more  sohible  in  solutions  of  urea. 
Tt  does  not  occur  often  as  free  uric  acid,  but  usually  is  combined  with  sodium, 
jiotassium  and  ammonium  to  form  urates.  When  a  strong  acid  is  added  to  a 
iii'ine  containing  the  neutral  salts  of  uric  acid  wliich  ai'c  soluble,  a  ilcposit  of 
insoluble  acid  urates  occurs.  Uric  acid  crystallizes  in  the  uriue  in  rectangular 
ju-jsuis,  in  wedges,  whetstone  shapes  and  rosettes  of  a  yel- 
lowish-red color. 

Qualitative  Tests  for  Uric  Acid. — Qualitative  tests  for 
uric  acid  are  of  no  clinical  value.  The  following  three 
tests  uuiy  be  used  in  recognizing  the  acid. 

Xo.  1.  Put  a  drop  of  urine  on  a  slide,  add  a  drop  of 
uifric  acid,  warm  over  a  spirit  lamp.     After  evaporation 


0.175 
0.178 
f  181 
0,194 
0.187 
0,190 
0,193 
0196 
0,199 
If  0.202 


=S- 


thc  characteristic  crystals  of  urea  nitrate  Avill  be  discov- 
ered by  the  microscope. 

Xo.  2.  Put  a  few  drops  of  urine  in  a  test-tube,  add  an 
equal  amount  of  solution  of  sodium  hypobromite.  If  urea 
is  present  there  will  be  a  rapid  formation  of  bubbles. 

Xo.  3.  Warm  a  few  crystals  of  urea  in  a  test-tube,  add 
a  trace  of  sodium  hydrate,  and  then  a  drop  of  a  dilute  solu- 
tion of  cupric  sulphate.  A  violet  or  rose  color  will  de- 
velop in  the  presence  of  urea:  this  is  called  the  biuret 
reaction. 

Quantitative  Estimation  of  Uric  Acid. — There  is  no 
accurate  method  of  estimating  uric  acid  which  is  sufficient- 
ly convenient  for  clinical  purposes.  The  following  methods 
are  described  because  they  are  less  troublesome  than  any 
other  devised : 

IIeintz's  Method. — Add  10  e.c.  hydrochloric  acid  to 
200  c.c.  urine  and  let  it  stand  twenty-four  hours  in  a  cool 
place.  Weigh  a  filter  and  collect  the  deposited  crystals 
u])ou  it,  washing  with  cold  distilled  water.  Dry  the  filter 
thoroughly  and  weigh.  Subtract  the  weight  of  the  filter 
alone  and  obtain  the  weight  of  the  uric  acid  in  200  c.c.  of 
ui'ine;  from  this  may  be  determined  the  amount  in  the 
total  daily  urine.  Always  filter  the  urine  before  using 
this  method. 

Pukemann's    ukicometer    is    recommended    for    the 
rai)id   estimation   of   uric    acid    (Fig.    8G).      The   lowest 
nuirk   (S)   shows  the  height  to  which  the  indicator    (car- 
bon (lisulpliid)   should  reach.      Then  follows  to  the  mark  I,  a  space  of  2  c.c. 
content  into  which  iodin  solution  is  poured.     This  solution  is  composed  of  iodin, 
1.5  ;  potassium  iodid,  1.5  ;  alcohol,  15.0 ;  water,  185.0.   Above  the  mark  I,  at  2.6, 


Fig.  86.  —  Ruhemann's 
Uricometer  for  the 
Rapid  Estimation  of 
Uric  Acid. 


86  THE    T'RINE 

begins  an  empiric  scale  which,  at  distances  of  0.2  c.c,  gives  the  uric  acid  vahie 
pro  millc.  After  the  carbon  snlphid  and  iodin  solution  have  been  placed  in  the 
burette,  tlic  urine  is  slowly  added  and  the  iiiixtiire  strongly  shaken  after  each 
addition.  The  nrine  is  added  nntil  the  primary  brown  color  gives  ])lace  to  a 
white  one,  at  which  moment  the  percentage  of  uric  acid  is  read  off  at  the  top  of 
the  column  of  fluid.  If  the  urine  contains  less  uric  acid  than  the  apparatus 
will  indicate,  add  the  iodin  only  to  the  mark  midway  between  I  and  S  and  read 
lialf  values.  Alkaline  urines  should  be  acidulated  with  acetic  acid,  and,  if 
abundant  sediment  of  sodium  urate  is  present,  the  specimen  should  first  be 
well  shaken.  Traces  of  sugar  and  albumin  do  not  interfere,  but  if  large 
amounts  of  pus  or  blood  are  present,  these  should  be  removed  by  heat  and  fil- 
tration.    The  procedure  requires  about  from  thirty  to  forty-five  minutes. 

Urates 

Xearly  all  the  uric  acid  in  the  urine  exists  in  the  fonn  of  urates,  i.  c.,  salts 
of  potassium,  sodium,  annnonium,  calcium  and  magnesium.  These  salts  are 
soluble  at  body  temperature,  but  a  large  part  of  them  precipitate  on  cooling 
the  urine. 

Two  kinds  of  urates  are  found:  the  acid  and  neutral  urates.  'I'hc  acid  salts 
are  less  soluble  and  are  more  readily  precipitated.  When  the  neutral  urates 
are  in  excess,  they  often  remain  dissolved  for  some  time  and  precipitate  only 
when  the  urine  turns  more  intensely  acid.  (See  Acid  Fermentation.)  The 
addition  of  acid  to  such  urines  also  makes  the  urates  insoluble  and  pre- 
cipitates them,  as  they  are  converted  into  acid  urates.  On  heating,  the 
precipitate  of  urates  is  dispelled.  Urates  usually  precipitate  in  the  form  of 
amorphous  grannies,  which  may  be  mixed  with  uric-acid  crystals  if  the  urine 
has  been  allowed  to  stand. 

HiPPURic  Acid 

Hippuric  acid  exists  normally  in  quantity  from  0..^)  to  1.0  gram  and  is  in- 
creased by  vegetable  and  fruit  diets,  by  certain  drugs  like  benzoic  acid,  and  in 
some  diseases,  like  chorea,  diabetes,  and  acute  fevers. 

DiACETic  Acid 

Diacetic  acid  occurs  in  the  urine  in  the  advanced  stages  of  diabetes.  It  is 
usually  a  grave  symptom,  giving  warning  of  approaching  coma  and  death. 

ACETOXE 

Acetone  is  a  colorless,  thin,  watery  fluid  of  a  fruity  odor,  occurring  in  the 
urine  and  blood  in  diabetes  and  malignant  tumors ;  also  at  times  in  high  fever, 


i 


PLATE    I 


ir-^^-^ 


Fig.  1. 
Normal  Urine. 


^' 


Fig.  2. 
Simple  Indicanuria. 


fT 


w 


Fig.  3. 
Potassium  Iodid  Reaction. 


INDICAN    COLOR   REACTION    IN   URINE.     (After  W.  H.  Porter.) 


88  THE   URINE 

Bile  Pigment 

The  presence  of  biliary  pignients,  l)iliu,  and  Ijilivcrdin,  indicates  derange- 
ment of  the  liver  or  biliary  tract.  They  are  always  formed  in  the  nrine  in 
janndiee,  due  to  obstruction  of  the  common  duct  and  after  an  attack  of  hei)atic 
colic.  Biliary  pigments  impart  a  greenish-yellow  color  to  the  urine  and  the 
foam  produced  by  shaking  the  specimen  vigorously  has  a  yellow  tint. 

Gmelin's  Test. — A  modification  of  Heller's  albumin  test,  known  as  Gmelin's 
test,  is  connnonly  used,  to  demonstrate  the  presence  of  these  pigments  in  the 
urine. 

In  a  test-tube  the  urine  is  carefully  deposited  on  top  of  a  small  quantity  of 
fuming  nitric  acid,  to  which  has  been  added  yellow  nitrous  acid.  A  greenish 
ring  a23pears  at  the  point  of  contact  if  the  urine  contains  bilin  or  biliverdin. 
There  are  several  modifications  of  this  test.  A  drop  of  the  same  acid  on  the 
white  filter  j^aper,  through  which  the  specimen  has  been  filtered,  will  give  a 
similar  reaction. 

lodin  Test  for  Bile. — A  solution  of  one  part  of  tincture  of  iodin  (or  Lugol's 
solution)  to  nine  parts  of  water,  overlaid  on  the  urine  in  a  test-tube,  produces 
a  distinct  green  color  at  the  point  of  contact  of  the  urine  and  reagent  if  bile  is 
present. 

Hemoglobia^ueia 

Hemoglobinuria,  or  the  presence  of  hemoglobin,  the  coloring  matter  of  blood 
in  solution  in  the  urine,  is  of  rare  occurrence.  Under  normal  circumstances, 
hemoglobin  is  a  constituent  part  of  the  red  blood  corpuscles  and  is  not  found 
in  the  urine  separate  from  them. 

Hemoglobinuria  has  been  found  with  more  or  less  frequency  in  severe  tyj)es 
of  infectious  diseases,  especially  yellow  fever,  scarlet  fever ;  also  in  ])urpura, 
scurvy  and  malaria.  It  occurs  also  in  severe  burns  and  in  poisoning  by  coal-tar 
phenol  derivatives,  carbolic  acid  and  naplithol. 

Heller's  Test  for  Hematin. — By  adding  a  little  caustic-potash  solution  and 
gently  heating  the  urine,  the  earthy  phosphates  are  precijjitated.  The  pre('i])i- 
tate  carries  the  blood-coloring  matters  with  it  as  it  sinks  and  is  stained  red.  If 
the  urine  is  alkaline,  the  phosphates  can  be  precipitated  by  adding  a  few  drops 
of  magnesium  fluid  and  heating  gently.     (See  page  01.) 

Test  for  Hemin  Crystals. — The  precipitated  earthy  phosphates  are  filtered 
and  placed  on  an  object  glass  and  warmed  until  completely  dry.  Add  a  minute 
granule  of  connnon  salt  and  mix  thoroughly,  cover  with  a  thin  cover  glass  and 
then  allow  a  drop  or  two  of  glacial  acetic  acid  to  pass  underneath  the  cover  glass. 
The  slide  is  carefully  warmed  until  bubbles  make  their  appearance.  After 
cooling,  hendn  crystals  can  be  seen  by  the  aid  of  the  microscope. 


CHEMICAL    EXAMlXATlOx^    OF    THE    UKINE  89 

Melanin 

j\rclaiii'n  is  a  ])iiiiiiont  found  in  cases  of  melanotic  cancer  or  sarcoma,  and 
occurs  citlicr  in  solution  in  the  urine,  or  is  deposited  in  small  black  ])arti- 
cles.  j\Ielanin  also  occnrs  rarely  in  severe  wasting  conditions  and  in  chronic 
malaria. 

To  detect  melanin,  add  bromin  water  to  the  nrine,  which  canses  a  yellow 
I>recipitate  that  gradtndly  blackens.  On  adding  ferric  chlorid,  the  nrine  turns 
gray ;  if  enough  be  added,  the  phosphates  will  precipitate,  carrying  the  coloring 
matter  with  them.  The  nrine  containing  melanin  is  normal  in  appearance 
when  freshly  voided,  bnt  on  exposnre  to  the  air  becomes  brown  or  black. 

Organic  Constituents  of  Minok  I:mportance 

Leucin  and  tyrosin  are  f otnid  in  the  nrine,  chiefly  in  destructive  diseases 
of  the  liver  (acute  yellow  atrophy,  phosphorous  poisoning)  and  in  acute  infec- 
tions (smallpox,  typhus). 

Leucin  and  tyrosin  usually  occur  together ;  they  may  be  deposited  in  the 
sediment  when  present  in  large  amounts.  Usually  the  urine  contains  an  excess 
of  bile  and  a  deficiency  of  urea. 

The  crystals  may  be  obtained  by  evaporating  the  urine  and,  if  the  crystals 
are  extracted  with  alcohol,  leucin  dissolves  and  tyrosin  is  left. 

Inorganic  Constituents 

The  principal  inorganic  constituents  of  the  urine  are  the  chlorids,  phos- 
phates and  sulphates  occurring  in  combination  with  sodium,  potassium,  am- 
monium, calcium  and  magTiesium.  The  total  amount  of  inorganic  substances 
excreted  in  twenty-four  hours  varies  between  nine  and  twenty-five  grams. 

Chlorids 

The  chlorids  rank  next  to  urea  in  importance  among  the  solid  constituents 
of  the  urine.  The  greater  part  of  the  chlorids  exist  as  sodium  chlorid,  while 
smaller  amounts  of  potassium  and  annnonium  chlorids  are  found.  The  chlorids 
in  the  urine  are  derived  from  the  food,  and  most  of  the  salt  ingested  is  elim- 
inated in  the  urine  as  such. 

The  nornuil  amotnit  of  chlorids  excreted  in  twenty-fotir  hours  varies  frcnn 
ten  to  twenty  grams,  but  if  much  salt  is  taken  with  the  food,  the  amount  may 
reach  fifty  grams.  Chlorids  are  diminished  especially  in  all  acute  affections, 
in  which  there  is  a  serous  exudation  or  transudation,  vomiting,  or  diarrhea. 
Chlorids  are  diminished  or  absent  also  in  cholera,  septicemia,  pyemia,  puer- 
peral fever,  and  acute  artictdar  rheumatism.      The  chlorids  may  be  absent  in 


90  THE   URIXE 

the  urine  in  a  chronic  disease,  if  accompanied  by  dropsy  (chronic  nephritis, 
heart  disease),  and  as  the  dropsy  is  absorbed,  the  chlorids  gradually  are  in- 
creased. In  pneumonia,  the  chlorids  are  low  or  absent  in  the  acute  stage,  but 
as  the  exudate  becomes  absorbed,  they  increase,  and  may  become  normal.  In 
lueningitis  (acute)  the  chlorids  are  also  increased,  so  that  by  testing  for  them, 
we  may  differentiate  between  meningitis  and  typhoid.  In  nephritis,  the  amount 
of  chlorids  eliminated  as  compared  to  the  amount  of  urea,  is  of  considerable 
iniportaiico. 

Detection  and  Approximate  Estimation. — Sit.ver  Xitrate  Tkst. — De- 
fore  applying  this  test,  if  more  than  a  trace  of  all)uniin  is  present,  it  should  be 
removed  by  heat,  as  albuminate  of  silver  forms  and  interferes  with  the  reac- 
tion. One  half  ounce  of  urine  is  laid  upon  an  equal  amount  of  pure  nitric  acid 
in  the  same  manner  as  in  the  test  for  albumin.  Then  one  drop  of  a  1 :  8  solu- 
tion of  silver  nitrate  in  water  is  added.  A  jDrecipitate  of  silver  chlorid  is 
formed,  which,  if  normal  or  increased  in  amount,  appears  as  a  compact,  solid 
mass  which  falls  to  the  surface  of  the  nitric  acid.  If  the  amount  is  diminished, 
the  silver  chlorid  becomes  more  or  less  diffused  through  the  layer  of  urine. 

Carbonates 

Minute  quantities  of  carbonates  and  bicarbonates  of  sodium,  ammonium, 
calcium,  and  magiiesium,  are  found  in  fresh  urine  of  alkaline  reaction.  Am- 
monium carbonate  may  occur  in  large  amounts,  owing  to  alkaline  decomposi- 
tion. The  carbonates  in  urine  are  derived  from  the  food,  especially  from  vege- 
table acids,  such  as  lactic,  tartaric,  malic,  succinic,  etc.  They  are,  therefore, 
most  abundant  in  the  urine  of  herbivora.  An  excess  of  carbonates  renders  the 
urine  turbid  when  passed  or  on  standing  and,  as  a  rule,  the  sediment  is  mixed 
with  phosphates. 

Detection, — On  the  addition  of  an  acid,  the  presence  of  carbonates  is  de- 
tected by  the  evolution  of  gas  bubbles,  and  this  gas,  wdien  passed  into  baryta 
water,  renders  the  latter  turbid.  The  determination  of  the  amount  of  carbonic 
acid  will  be  found  described  in  the  larger  text-books. 

Phosphates 

Earthy  Phosphates. — Render  half  a  test-tubeful  of  filtered  urine  alkaline 
with  ammonia  and  warm  gently.  Earthy  phosphates,  in  the  form  of  a  wliirish 
cloud,  settle  to  the  bottom  of  the  tube.  The  precipitate  is  dissolved  by  the 
addition  of  acetic  acid. 

Approximate  Quantitative  Estimation  (Ultzmaiin). — A  test-tube  2  cm. 
wdde  is  filled  with  urine  to  the  depth  of  5-j  cm.,  and  a  few  drops  of  strong 
ammonia  are  added.  The  mixture  is  w'armed  over  an  alcohol  lamp  until  the 
earthy  phosphates   separate.      The   depth  of  the  sediment  is  measured   after 


CHEMICAL   EXAMINATION    OF    THE    URINE  91 

staiidinii;  for  fiftcon  iiiinutes.  IS^ornially,  the  layer  Avill  be  1  cm.  liiuli: 
;i  <;reater  depth  indicates  an  increase,  while  a  less  abundant  precipitate  means 
diminution. 

Alkaline  Phosphates. — After  the  earthy  phosphates  have  been  separated, 
as  shown  above,  the  mixtui'c  is  filtered.  To  the  filtrate  is  added  one  third  of 
its  volume  of  niai!,nesinm  fluid  (magnesium  sulphate,  ammonium  hydrate,  am- 
monium chlorid,  of  each  one  part;  water  eight  parts).  The  white  precipitate 
consists  of  alkaline  phosphates.  To  make  this  test  available  for  approxinuite 
estimation,  according  to  Ultzmann,  10  c.c.  of  the  urine  are  treated  with  3  e.c. 
of  the  magnesium  fluid.  A  precipitate  of  crystalline  ammonio-magiiesium 
])hosphate  is  found,  together  with  an  amorphous  mass  of  calcium  phosphate. 
If  a  milky  turbidity  permeates  the  entire  fluid,  the  alkaline  phosphates  are 
normal  in  amount.  If  an  abundant  precipitate  gives  the  fluid  the  appearance 
of  cream,  they  arc  greatly  increased ;  and  if  a  slight  turbidity  follows,  or  if 
the  fluid  remains  transj)arent,  they  are  decreased. 

Sulphates 

The  ethereal  sulphates  have  already  been  considered.  There  are  in  addition 
in  the  urine  the  ordinary  alkaline  sulphate  of  sodium  and  potassium,  the  sodium 
salt  being  present  in  larger  quantities.  The  amount  of  sulphates  excreted  by 
healthy  adults  ranges  from  1.5  to  5.0  grams  daily.  About  one  tenth  of  this 
11  mount  is  represented  by  the  ethereal  sulphates,  about  nine  tenths  represented 
by  the  potassium  and  sodium  salts. 

The  sulphates  in  the  urine  are  derived  partly  from  food  and  partly  from 
the  decomposition  of  proteid  substances  in  the  tissues.  The  sulphur  from  the 
foodstuffs  and  from  the  tissue  elements  is  oxidized  to  sulphuric  acid,  the  lat- 
ter in  turn  combining  with  sodium  and  potassium  to  form  a  sulphate  of  these 
bases.  The  amount  of  sulphates  in  the  urine  is  increased  after  taking  sulphuric 
acid  or  suljjhates ;  after  active  exercise ;  after  the  inhalation  of  oxygen  ;  in  acute 
fever,  in  meningitis  and  in  rheumatism.  As  a  rule,  the  amount  of  sulphates  is 
parallel  to  that  of  urea.  Sulphates  are  decreased  in  most  chronic  diseases  when 
metabolism  and  appetite  are  diminished ;  also  after  carbolic-acid  poisoning  or 
after  the  use  of  large  doses  of  salol,  etc.  In  such  cases  the  ethereal  sulphates 
are  increased. 

Detection. — For  ordinary  purposes,  the  following  test  is  sufficient:  To  a 
test-tube  one  half  full  of  filtered  urine,  add  one  or  two  inches  of  barium  solu- 
tion (barium  chlorid,  4  parts;  concentrated  hydrochloric  acid,  1  part;  distilled 
water,  10  parts).  A  white  precipitate  occurs  which  normally  fills  one  half  the 
concavity  of  the  test-tube.  A  larger  amount  indicates  an  increase,  a  smaller 
amount  a  decrease. 


92 


THE   UKINE 


IV.    MICROSCOPICAL    EXAMINATION 

General  Coksidkuatioxs 

To  obtain  the  sediment  of  a  specimen  of  urine  for  microscopical  examina- 
tion, we  can  use  either  the  okl-fashioned  gravitation  method  or  the  centrifuge. 
If  the  former  is  used,  the  specimen  must  bo  aHowed  to  stand  in  a  well-co\'ercd, 
conical  glass,  preferably  in  a  cool,  dark  place,  from  six  to  twelve  hours.  This 
method  has  the  obvious  disadvantages  of  delay  in  examination  and  more  or  less 
disintegration  of  the  organic  elements. 

Centrifugal  sedimentation  permits  the  inunediate  examination  of  the  urine 
microscopically  and  produces  a  concentrated  sediment  from  freshly  voided 
urine  before  cells  and  easts  can  be  destroyed  by  the  alkalinity  of  the  stand- 
ing urine  and  before  the  development  of  bacteria.      This  is  the  only  method 

by  which  crystals,  formed  in  the 
urine  before  it  is  passed,  can  be  dis- 
tinguished from  those  formed  after- 
wards. By  the  old  methods  in  urine 
of  high  specific  gravity,  the  lighter 
forms  of  casts  might  float  and  thus  be 
overlooked.  This  does  not  happen 
with  the  centrifuge. 


Fig.  87. — Hand  Centrifuge. 
(From  Kny-Scheerer.) 


Fig.  88. — Water  Centrifuge. 


The  Centrifuge. — Three  types  of  centrifuge  are  on  the  market:  the  hand 
(Fig.  87),  water  motor  (Fig.  88),  and  the  electric  centrifuge  (Fig.  89).  Of 
the  three,  the  hand  centrifuge  is  the  least  expensive  and  answers  the  purpose 


MTCEOSCOPICAL   EXAMINATION 


93 


wliere  it  is  impossible  or  iinpractieal)lo  to  use  eitlicr  a  water  or  electric  centri- 
fii<;e.  The  labor  and  time  re(iuired  in  using  it,  owing  to  the  limited  speed  ob- 
tainable, are  obvious  disadvantages. 

The  water  motor  is  in  many  ways  the 
most  practical.  It  can  be  used  wherever 
I  hero  is  a  faucet  of  running  water  under 
ordinary  city  pressure  and  it  is  so  simple 
that  it  never  gets  out  of  order. 

The  electric  centrifuge  has  some  ad- 
vantages, and  is  joreferred  by  laboratory 
workers  on  account  of  the  greater  speed 
ol)tainable.  It  can  be  run  with  ordinary  in- 
ciindeseent  lighting  currents  of  110  volts, 
direct  or  alternating,  or  even  by  currents  of 
K'ss  voltage. 

Aluminum  shields  protect  the  tubes  from 

all  danger  of  breaking,  no  matter  wdiat  the 

s])eod  may  be.     The  tubes  have  conical  tips 

in  which  the  sediment  collects,  and  it  is  not 

disturbed  by  sudden  stopping  of  the  instru-     ^  _      ^  ^  ^ 

•^  ,  .  Fig.  89. — The  Purdt  Electric   Centri- 

ment  or  by  decanting  the  urine.  fuge. 


Methods  of  Examining  the  Sediment 

A  pipette,  consisting  of  a  single  glass  tube,  drawn  to  a  moderate  point,  is 
held  with  its  upper  opening  tightly  closed  with  the  index  finger  and  dipped  to 
the  bottom  of  the  sediment  glass  of  the  centrifuge  tube.  The  finger  is  then 
released  and  the  sediment  is  allowed  to  rush  in  from  below  upward.  A  speci- 
men should  include  portions  of  all  strata  of  the  sediment,  mixed  with  a  little 
urine,  especially  if  the  sediment  is  very  dense. 

The  sediment  is  dropped  upon  a  slide  and  covered  with  a  large  cover  glass. 
The  excess  of  urine  is  taken  up  with  filter  paper.  When  the  low  power  (only 
I  objective)  is  used,  no  cover  glass  is  needed,  but  for  the  high-power  lens  a 
cover  glass  is  essential  to  prevent  soiling  the  lens,  the  microscope  and  the  ex- 
aminer's fingers. 

It  is  best  to  go  over  a  slide  with  the  low-powerTens  (Leitz  Xo.  3,  Zeiss  A  A, 
Bausch  &  Lomb  §).  With  this,  most  of  the  larger  elements  can  be  made  out. 
For  the  fine  study  of  epithelia,  casts,  etc.,  however,  the  higher  power  (Leitz 
Xo.  (i,  Zeiss  D,  Bausch  &  Lomb  \^)  is  necessary.  For  the  routine  examination 
ot  a  large  uuud)er  of  specimens  without  a  cover  glass,  the  lower  ]iower  with  a 
stronger  eyepiece  (Zeiss  No.  12,  Achromatic  or  Leitz  Ko.  3,  Ocular  5)  will 
be  found  sufficient.     In  fact  this  combination  offers  a  rapid,  cleanly  way  of  ex- 


94  THE    l^KIXE 

aiiiining'  urine,  wliieli  will  appeal  to  the  busy  practitioner.     For  differentiating 
epithelia  and  the  liner  structures,  however,  it  cannot  serve  in  all  instances. 

In  searching  for  casts,  especially  of  the  hyaline  variety,  the  diaphragm  of 
the  microscope  should  be  closed  so  as  to  admit  the  least  possible  amount  of  light. 
The  micrometer  screw  of  the  microscope  should  be  freely  used  in  looking  for 
casts,  as  these  structures  are  cylindric  and  often  so  trocated  that  one  turn  of 
the  screw  brings  one  part  into  view,  while  the  rest  remains  hazy.  The  flat 
mirror  should  be  used  when  looking  for  casts.  The  Abbe  condenser  should  not 
be  used  when  looking  at  urinary  sediment. 

UlS'OROANIZEI)    SeDIMEIs^T 

Uric-Acid  Calculi. — In  uric-acid  calculi  in  the  kidneys  or  elsewhere  in  the 
urinary  tract,  considerable  masses  of  uric-acid  crystals,  with  jagged  outlines, 
may  be  found  in  the  urine. 

Detectiox. — Uric-acid  crystals  (Figs.  90,  91,  92)  vary  greatly  in  shape, 
but  the  typical  forms  are  the  rhom1)ic,  or  six-sided  plates,  the  whetstone  shape 


4  .*:'V  ^ 


Fig.  90. — Crystals  of  Uric  Acid.     (From  Wood.) 

in  stellate  groups  and  crystals  resembling  a  comb  with  teeth  on  both  sides.  All 
these  are  more  or  less  yellow  in  color,  though  occasionally  some  of  them  appear 
colorless.  They  dissolve  on  adding  a  few  drops  of  alkali  and  reappear  on  add- 
ing acetic  acid. 


MICROSCOPICAL   EXAMINATION 


95 


Urates. — The  mixed  sodium,  potassium,  ammonium,  calcium  and  mag- 
ne?iuiii  urate  deposit  is  a  granular  sediment  of  a  rcddisli  color,  varying  from 
piiik  to  l)ri('k-red,  and  usually  sinks  (prickly,  tliougli  it  uiiiy  make  the  urine 
turbid.     Tiie  ])r('('ipitate  redissolves  on  gently  heating  the  urine. 


Fig.  91. — Unusual  Forms  of  Uric  Acid. 


Fig.  92. — Unusual  Forms  of  Uric  Acid. 


K    ^ 


■^ 


Sodium  Ur.vte. — This  forms  the  greater  bulk  of  the  mixed  urate  deposit, 
and  is  usually  amorphous.  It  is  generally  found  in  mosslike  masses  of  mi- 
nute granules  which  easily  adhere  to  larger  masses  of  sediment.  When  crys- 
talline, it  is  seen  in  the  form  of  fan-shaped  groups,  pointed  at  the  center,  or 
arranged  like  sheaves  of  wheat.     These  crystals  show  characteristic  striation. 

Potassium  Ueate. — This  occurs  always 
as  an  amorphous  sediment,  forming  a  part  of  ^■ 

the  mixed  urate  deposit.     It  is  soluble  in  hot 
water,  insoluble  in  cold  water. 

Calcium  Urate. — It  is  a  rare  deposit  and 
is  found  as  a  part  of  the  amorphous  mixed 
urate  sediment. 

Ammoxium  Urate. — It  is  said  by  some 
that  this  is  in  reality  sodium  urate  in  modi- 
fied form,  marking  a  transition  of  an  acid 
sediment  into  an  alkaline.  Ammonium  urate 
is  characteristic  of  alkaline  fermentation,  and 
is  usually  associated  with  triple  phosphate 
and  calcium  phosphate.  It  occurs  in  the 
form  of  yellowish-red  or  dark-brown  spher- 
ules, studded  with  fine  sharp  thorns  which 
have  given  rise  to  the  term  "  thorn-apple  " 
crystals  (Fig.  93). 

These  crystals  may  be  massed  in  clum])s 
or  chains  and  are  soluble  in  hot  water  or  in  acids ;  they  emit  the  odor  of  am- 
monia on  adding  alkalies.     It  is  the  onlv  urate  found  in  alkaline  urine. 


\ 


Fig. 


93.  —  Crystals    of    Ammonium 
Urates.     (From  Wood.) 


96 


THE    URINE 


Calcium  Oxalate. — Xormally  the  greatest  part  of  the  oxalic  acid  taken  in 
the  food  is  coinerled  by  oxidation  into  nrea  and  carbonic  acid.     When  for  some 

reason  (disease)  this  oxidation  is  inter- 
fered with,  this  change  (h)es  not  take 
jjUico,  then  the  oxalic  acid  is  excreted  as 
such  in-  combination  with  calcium  (from 
the  blood,  also  derived  from  food  and  tis- 
sues). 

Detection. — The  crystals  of  calcium 
oxalate  may  be  found  in  acid  urine  when 
they  may  accompany  crystals  of  uric  acid, 
or  in  alkaline  urine  w^hen  they  accompany 
triple  phosphates.  Two  typical  forms  of 
calcium  oxalate  crystals  are  distinguished 
Fig.   94. — Calcium    Oxalate    Crystals      (Fio".    94). 

The  octahedral  crystals  consist  of  two 
four-sided  pyramids  placed  base  to  base  and  appear  like  squares  crossed  like 
envelopes,  or,  if  turned  with  their  long  axes  toward  the  observer,  like  long- 


FiG.  95. — Crystals  of  Ammonium  Magnesium  Phosphate.     (From  Wood.) 


pointed  octahedra.  Sometimes  these  crystals  coalesce  with  larger  masses.  The 
dumb-bell  crystals  are  not  so  common  and  look  like  two  crossed  dumb-bells. 
They  must  be  distingiiished  from  the  yellow  or  brown  dumb-bells  of  uric  acid. 


MTCKOSCOPICAL   EXAMINATION 


97 


Fig.  96. — Featheey  Form  of  Triple 
Phosphates. 


The  (]uinl)-l)('ll.s  of  ealciuni  oxalate  are  solul)lc  in  hydrochloric  acid,  those  of 
uric  acid  in  alkalies. 

Phosphates. — In  the  sediment  the  earth}'  j)liosj)hates  are  represented  hy  cal- 
cium |)li()S|)hate  and  by  ammonio-magnesia  phos- 
])liate  (tri})le  phosphate,  so  called).  The  alkaline 
])hosphates  are  not  represented  in  the  sediment. 
Calcium  Phosphate. — Calcinm  phosphate 
is  either  amorphons  (the  normal  salt),  or  crys- 
talline (the  acid  salt),  the  latter  consisting 
jiartly  of  magnesium  phosphate.  The  amor- 
phous form  occurs  in  feebly  acid  urines  and  is 
seen  in  small,  highly  refractive  granules,  in 
elnni])s  or  adhering  to  other  parts  of  the  sedi- 
ment. The  crystalline  form  is  found  in  urine 
about  to  undergo  alkaline  fermentation,  but 
Avliieli  is  still  weakly  acid.  They  are  prismatic 
and  arranged  in  either  single  or  in  star-shaped, 
often  in  fanlike,  groups.  Acetic  acid  rapidly 
dissolves  them,  whereas  it  slowly  affects  sodium- 
urate  crystals  similarly  shaped. 

Teiple  Phosphate  Crystals. — Ammonio-magnesium  phosphate  occurs 
either  as  the  coffin-lid  crystals  or  the  feathery  crystals.  The  former  is  more 
common  and  consists  of  a  triangular  prism  with  one  of  the  three  angles  wanting. 
They  are  large  in  size  and  at  times  shortened  into  squares  which  may  be 
mistaken  for  calcium  oxalate.  The  stellate  crystals  are  feathery  stars  or  parts 
of  stars.  The  phosphate  crystals  are  soluble  in  acetic  acid,  while  the  oxalate 
crystals  are  insoluble  in  this  acid. 

Carbonates    and    Sulphates. — (a)    Calcium    Carbonate. — Calcium    car- 
bonate is  found  rarely  in  the  urine  of  man,  but  in  large  quantities  in  the  urine 

of  some  lower  animals.  It  occurs  in  the  form 
of  small  squares.  On  adding  acetic  acid,  an 
effervescence  of  carbon  dioxid  results. 

(h)  Calcium  Sulphate. — Calcium  sul- 
phate is  a  very  rare  deposit ;  it  occurs  in 
highly  acid  urine  with  high  specific  gravity, 
in  the  form  of  needlelike  prisms  which  often 
are  grouped  in  radiating  fanlike  arrange- 
ments (Fig.  97). 

Leucin  and  Tyrosin. — (a)  Leucix  occurs 
in    the    form    of   yellowish,    highly    refractive 
s])heres,   looking  like  oil   drops    (Fig.    98),   which   show   radiating  or   concen- 
tric stripes.     They  are  often  arranged  in  masses  or  groups  of  three  or  more 


Fig.  97. — Crystals  of  Calcium  SuL' 

PHATE. 


98 


THE   I^RINE 


spheres.      Unlike  oil,  leucin  is  not  soluble  in  other,  but  is  soluble  in  alka- 
lies.    They  are  larger  than  the  spheres  of  anniioiiiuui  urate  and  have  no  spikes. 


Fig.  98. — Leucin  Crystals. 
(From  Jacob.) 


Fig.  99. 


-Leucin  and  Tyrosin  Crystals. 
(From  Wood.) 


(h)  Tykosust  occurs  as  very  fine  needles  arranged  in  sheaves  or  rosettes 
(Fig.  99).  They  are  colorless,  but  when  arranged  in  masses,  they  appear  quite 
dark.     They  are  insoluble  in  ether,  but  soluble  in  alkalies. 

Blood  and  Bile  Pigments;  Fat;  Cholesterin. —  (a)  Bilirubin. — In  urine 
containing  bile,  bilirubin  may  be  found  as  amorphous  masses,  or  as  needles  in 
stellate  formations,  often  adherent  to  cells,  or  in  yellow  or  ruby-red  rhombic 
plates.     They  show  a  green  rim  on  adding  nitric  acid. 

(h)  Hematoidin. — Crystals  of  hematoidin  occur  in  nrine  containing  blood, 
e.  g.,  after  an  extensive  hemorrhage,  in  pyonephrosis,  renal  stone,  etc.  The 
crystals  are  identical  with  those  of  bilirubin  and  probably  hematoidin  is  iden- 
tical with  the  former. 

(c)  Fat  Globules. — Fat  globules  may  be  seen  in  the  urine  as  extraneous 
matter  from  unclean  bottles,  or  from  ointments  in  the  genitals.  "When  enough 
fat  is  present  to  be  seen  with  the  naked  eye,  the  term  "  lipuria  "  is  used.  When 
the  fat  makes  the  urine  milky,  the  term  "  chyluria  "  is  used.  The  latter  is 
usually  due  to  the  presence  of  a  parasite,  the  Filaria  sanguinis. 

Fat  in  small  amounts  may  occur  in  healthy  urine  after  a  fatty  diet,  also  in 
pregnancy  and  in  phosphorous  poisoning.  j\Iany  minute  fat  globules  are  found 
in  the  urine  of  chronic  nephritis  in  which  the  fat  granules  are  derived  from 
disintegrated  fatty  epithelia.  They  are  found  also  in  other  chronic  inflamma- 
tions, such  as  cystitis,  pyelitis,  prostatitis,  urethritis  and  vaginitis,  in  cystic 
kidney,  and  in  abscesses  opening  into  the  ureter. 

(d)  Cholesterin. — Cholesterin  is  a  monatomic  alcohol,  normally  present 
in  the  blood,  the  nerve  tissues,  the  bile,  etc.  It  occurs  in  gall-stones,  in  pus,  tu- 
mors, etc.,  but  is  a  rare  deposit  in  the  urine  in  extensive  fatty  changes  in  the 
kidney  as  a  result  of  acute  or  subacute  or  chronic  nephritis.     Still  more  rarely 


I 


MICROSCOPICAL   EXAMINATION 


99 


Fig.  100. — Crystals  of  Cystin. 
(From  Jacob.) 


it  occurs  in  choosy  (loi>'oncration  of  cystic  kidnoys.  It  crystallizes  in  large 
])lates,  is  insoluble  in  Avater,  l)ut  soluble  in  alcohol,  etlier,  chloroform,  etc.  If 
a  mixture  of  five  parts  of  sulphuric  acid  is  allowed  to  act  on  a  cholesterin  plate, 
a  bright  carmine-red  color  appears,  which  changes  to  violet. 

Cystin. — Cystin  is  seldom  found  as  a  urinary  sediment  and  ])i'<»l)ably  never 
in  normal  conditions.  Its  origin  in  the  econ- 
omy is  not  clearly  nnderstood,  but  the  liver 
is  regarded  as  the  seat  of  its  formation.  It  is 
a  crystalline  compound  and  occurs  in  two 
forms;  either  as  hexagonal  tablets  with  an 
opalescent  luster,  or  as  four-sided  prisms.  It 
is  soluble  in  caustic  alkalies,  oxalic  and  strong 
mineral  acids,  insoluble  in  boiling  water, 
acetic  acid,  ether  and  alcohol.  These  crystals 
may  be  distinguished  from  uric  acid  by  treat- 
ing them  with  strong  acid — which  dissolves 
them  but  not  uric  acid — and  from  triple 
])hosphates  by  the  solubility  of  the  latter  in 
acetic  acid  (Fig.  100). 

Clinical  Significance. — But  little  is  known  as  yet  of  the  interpretation 
of  cystin  in  the  urine.  It  is  found  in  typhoid  fever,  in  renal  degeneration,  in 
chlorosis,  and  acute  rheumatism.     It  occasionally  forms  calculi. 

Okganized  Sediments 

1.  Blood  Cells. — As  a  urinary  sediment,  blood  cells  are  always  pathological. 
Their  form  depends  upon  the  source  of  the  bleeding  and  the  reaction  of  the 
urine ;  when  the  typical  biconcave  disks  are  preserved,  it  is  easy  to  recognize 

them  by  the  microscope  and  in  acid  urine  they  retain  their 
shape  for  a  long  time,  gradually  shriveling  and  becoming 
crenated  (Fig.  101).  They  seldom  form  rolls  as  when  drawn 
from  a  blood  vessel,  except  in  cases  of  great  hemorrhage  from 
bladder  or  urethra.  If  the  urine  be  concentrated,  the  biconcave 
form  is  exaggerated  and  the  corpuscles  shrink 
and  become  crenated ;  when  the  urine  is  of 
low  specific  gravity,  they  swell  and  may  be- 
come spherical. 

2.  Pus. — Pus  cells  may  be  derived  from  any  part  of  the 
urinary  tract.  The  urine  containing  pus  is  usually  turbid 
and  gives  the  albumin  reactions.  Under  the  microscope,  the 
pus  cells  appear  as  circular,  pale,  finely  granular  disks, 
about  twice  the  size  of  the  red  blood  cell ;  they  contain  distinct  nuclei,  often 
two  or  three  (Fig.  102).     \Yater  swells  the  pus  cell,  renders  it  paler  and  ob- 


0 


m 
©a  @ 

Fig.  lOL — Blood 
Cells  in  the 

UlUNE. 


Fig.  102.— Pus  Cells 
in  the  Urine. 


100  TTIK   URINE 

sciires  its  outlines ;  acetic  acid  produces  the  same  effect,  more  quickly,  and, 
causing  the  granular  condition  to  disap^jear,  renders  the  nuclei  very  distinct. 
Pus  cells  resemble  the  white  cells  of  the  blood  and  lymph,  and  in  the  fresh  state 
present  the  glistening  appearance  of  living  protoplasm  and  also  ameboid  move- 
ments ;  seen  in  the  urinary  sediment,  the  cells  are  dead. 

The  chief  constituent  of  pus  cells  are  albuminous  bodies ;  especially  nucleo- 
albumin,  which  is  insoluble  in  water,  but  expands  into  a  tough  slimy  mass 
when  treated  by  sodium-chlorid  solution.  Pus  in  the  urine  is  usually  accom- 
panied by  tissue  elements  or  bacteria,  which  aid  materially  in  determining  its 
anatomical  and  pathological  source. 

3.  Epithelia. — In  normal  urine,  a  few  epithelial  cells  from  the  superficial 
layers  of  the  urinary  tract  are  always  seen  and  have  no  special  significance. 
When  these  cells  are  altered  by  disease  and  are  found  in  considerable  num- 
bers, accompanied  by  pus  or  red  blood  cells,  a  pathological  process  exists  in 
some  part  of  the  genito-urinary  tract. 

Theoretically,  each  separate  portion  of  the  urinary  tract  has  a  type  of 
epithelium  peculiarly  its  own,  but  in  actual  j^ractice  there  are  so  many  transi- 
tional forms  in  every  portion  of  the  tract,  that  it  is  not  always  possible  to  specify 
the  origin  of  a  given  cell.  Inasmuch,  however,  as  the  recognition  of  the  differ- 
ent characteristic  epithelia  is  absolutely  essential  to  a  localization  of  diseases 
of  the  tract  by  urinary  examination,  the  problem  of  distinguishing  the  epi- 
thelia of  each  portion  of  the  trac^  is  of  great  importance. 

Most  authorities  maintain  that,  while  histologic  preparations  of  the  dif- 
ferent urinary  organs  show  that  the  epithelial  lining  of  each  has  well-marked 
characteristics,  the  epithelia  shed  by  these  organs  during  life  and  appearing 
in  the  urine  are  radically  altered  in  aspect,  and  their  characteristics  to  a  large 
extent  obliterated.  Moreover,  the  same  school  of  clinical  pathologists  holds  that 
the  cells  of  the  deeper  layers  of  the  bladder,  for  example,  are  identical  in  ap- 
pearance with  cells  from  other  parts  of  the  urinary  tract. 

The  chief  characteristics  of  epithelia  found  in  the  urine  are  their  form  and 
size.  By  comparing  the  size  of  the  different  epithelia  with  that  of  the  leucocyte 
or  pus  cell,  we  have,  because  the  latter  varies  so  little,  a  fair  idea  of  the  relative 
magnitude  of  the  epithelial  structures. 

Three  chief  types  of  epithelia  occur  in  the  urine,  viz.,  the  flat  or  squamous, 
the  round  or  cuboidal,  and  the  columnar  or  caudate.  All  these  epithelia  have 
one  or  more  distinct  nuclei,  and  are  more  or  less  gTanular.  When  the  epithelia 
in  the  urinary  tract  are  stratified,  the  outer  layers  are  usually  flat,  the  middle 
layers  cuboidal,  the  inner  columnar. 

The  tubules  of  the  kidney,  tlie  prostatic  acini  and  ducts,  and  the  ejaculatory 
ducts  are  lined  with  a  single  layer  of  cuboidal  or  columnar  epithelium.  The 
pelvis  of  the  kidney,  the  ureters,  the  bladder,  the  urethra  and  the  vagina  are 
lined  with  stratified  epithelia. 


£ 


HiSTolooicAl    f^ppenRnNCE 

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Es  They  Occuii  iNTne  Uf^we. 


#  Tf.C. 


Fig.  103. — Epithelial  Cells  from  Different  Parts  of  the  Genito-urinary  Tract. 
I. — The  different  varieties  of  these  cells  as  seen  histologically. 


/?',  convoluted  tubules. 

R^,  spiral  tubules. 

R^,  descending     and     ascending 

limb  of  Henle. 
/?',  loop  of  Henle. 
R'\  distal  convoluted. 


R>,  arched  collecting  tubules. 
R',  straight  collecting  tubules. 
P,  pelvic  cells. 
U ,  ureteral  cells. 

Bs,  superficial  layer  of   bladder 
cells. 


Bd,  deep  layer  of  bladder  cells. 

S.  V,  seminal  vesicle. 

P.U,  prostatic  urethra, 

V.D,  vas  deferens. 

U.R,  penile  urethra. 

F.N,  fossa  navicularis. 


II. — The  groups  of  these  cells  recognized  in  the  urine. 
R.C,  epithelial   cells   from  renal       B,  superficial  bladder  cells.  C,  cells  belonging  either  to   pel- 

tubules.  Ur,  penile  urethra.  vis,  deeper  layers  of  bladder, 

P,  cells  from  renal  pelvis.  F.N,  fossa  navicularis.  prostate  or  ureter. 

III. — Comparative  size  of  epithelium  found  in  the  urine. 
/,  blood  cell.  4,  renal   pelvis,  ureter,    prostate       5,  superficial  layers  of  bladder. 

2,  pus  cell.  and    deeper  layers    of   blad-       f>\  the  penile  urethra. 

S,  cellsfromthcreualparenchyma.  dcr.  7,  the  vagina. 

101 


102  THE   URINE 

Tlie  largest  epithelia  in  the  urine  are  the  flat  superficial  cells  from  the  male 
anterior  urethra,  the  vagina,  vulva  and  female  urethra.  Xext  in  size  are  the 
superficial  squamous  layers  of  the  bladder.  Xext  come  the  cells  from  the  renal 
pelvis,  the  ureters,  the  prostate  and  the  tubules  of  the  kidney.  The  average  size 
and  the  average  shape  should  always  be  taken  into  consideration,  not  the  many 
transitional  sizes  which  are  confusing,     (See  Fig.  103.) 

(a)  Eenal  Epithelium. — These  cells  are  the  most  difficult,  yet  the  most 
important,  to  identify  in  the  urine.  They  do  not  occur  in  normal  urine,  save  in 
such  small  numbers  that  they  may  be  disregarded.  Their  presence  in  any 
numbers  is  indicative,  at  least,  of  renal  irritation ;  when  accompanied  by  or  ad- 
hering to  casts,  they  mean  nephritis. 

The  chief  diagnostic  characteristic  of  renal  cells  is  that  they  are  at  least 
one  third  larger  than  the  pus  corpuscles.  This  relation  is  constant.  If  the 
renal  epithelia  are  small  in  a  given  case,  the  pus  corpuscles  will  also  be  small. 
The  illustration  shows  the  comparative  sizes  of  pus  corpuscles  and  renal  epi- 
thelia. The  smallest  group  is  that  of  red  corpuscles,  which  are  the  smallest 
cellular  elements  in  the  urine.  The  next  group  is  composed  of  pus  cells.  Then 
follow  the  smallest  epithelia,  the  renal,  which  are  one  third  larger  than  the 
pus  cell.  The  next  group  shows  cuboidal  cells  twice  the  size  of  the  pus  cell. 
These  may  be  either  from  the  ureter  or  from  the  prostate. 

The  epithelia  from  the  straight  collecting  tubules  are  not  frequently  seen. 
They  are  about  the  same  size  as  the  epithelia  from  the  convoluted  tubule,  but 
narrower  and  columnar  in  shajDe. 

Renal  epithelia,  pus  and  pelvic  epithelia,  especially  when  accompanied  by 
casts,  are  indicative  of  a  pyelonephritis.  It  is  important  to  look  for  epithelial 
casts  and  to  compare  the  size  and  appearance  of  the  epithelia  on  these  casts 
with  other  renal  epithelia  found  free  in  the  urine.  In  this  way  we  often  con- 
firm our  opinion  that  a  given  set  of  round  cells  are  from  the  kidney.  It  is  al- 
ways important,  however,  to  compare  the  tubular  e2:)itlielia  with  the  pus  cell. 

(6)  Epithelia  from  the  Rexal  Pelvis. — These  cells  are  of  two  types. 
The  superficial  layers  shed  a  characteristic  caudate,  pear-shaped  or  lenticular 
cell.  The  deeper  layers  are  represented  by  round  or  cuboidal  cells,  smaller  than 
the  bladder  epithelia. 

The  caudate  cells  of  the  pelvis  are  distinguished  from  those  of  the  ureter 
and  from  the  columnar  cells  of  the  bladder  l)y  various  features.  The  pelvic 
cells  are  twice  the  size  of  a  pus  cell;  they  have  more  distinct  nuclei;  their 
granules  are  well  marked  and  they  often  have  jointed  or  bifurcated  tails.  They 
are  smaller  than  those  from  the  bladder  and  slightly  larger  than  those  from  the 
ureters.  The  presence  of  these  caudates  is  characteristic,  when  present  in  large 
numbers  and  accompanied  In-  pus,  of  pyelitis. 

The  round  cells  from  the  pelvis  are  not  so  characteristic,  and  fortunately 
are  not  so  frequently  seen,  as  they  may  be  confused  with  renal  cells.     They 


MICROSCOPICAL   EXAMINATION  103 

often  occur  in  clumps  of  considerable  size,  are  always  accompanied  by  pus,  and 
indicate  chronic  pyelitis. 

(c)  Epitiielia  from  the  Ureters. — These  occur  in  the  urine  of  uretero- 
pyelitis,  stone  in  the  ureter,  etc.  They  are  also  found  in  normal  specimens  ob- 
tained by  the  ureteral  catheter.  There  are  two  forms  of  ureteral  cells.  The 
majority  of  epithelia  from  the  ureters  are  round  or  cuboidal,  smaller  than  those 
of  the  pelvis  but  of  the  same  size  as  those  of  the  prostate.  They  rarely  occur 
without  pelvic  epithelia,  and  can  be  differentiated  only  when  the  renal  and 
])elvic  cells  are  present.  The  ureteral  epithelia  are  twice  the  size  of  a  pus  cell 
and  are  comparatively  rarely  seen.  They  resemble  a  small  narrow  caudate 
s})in(lk',  having  a  small  bright  nucleus.  These  cells  are  rarely  found  in  sedi- 
ments and  are  very  similar  to  those  of  the  deepest  layers  of  the  bladder,  but 
are  much  smaller. 

(d)  Epithelia  from  the  Bladder. — The  upper  layers  of  the  bladder 
strata  are  flat.  They  occur  in  moderate  numbers  in  normal  urines,  but  in  cys- 
titis and  other  bladder  diseases  are  greatly  increased  and  modified.  They  occur 
either  free  or  as  fragments  of  cells  irregular  in  size  and  shape.  The  largest  of 
these  flat  cells  are  found  near  the  neck  of  the  bladder,  and  are  apt  to  be  confused 
with  vaginal  cells.  The  average  superficial  bladder  cell,  however,  is  smaller  and 
has  more  rounded  outlines  than  the  vaginal  cells.  The  latter  also  often  contain 
bacteria. 

The  middle  layers  are  composed  of  cuboidal  epithelia.  These  are  present 
in  moderate  or  in  large  numbers  in  acute  cystitis,  in  conjunction  with  cells 
from  the  upper  layers.  When  chronic  cystitis  is  present,  the  middle  layers 
are  represented  by  a  majority  of  the  bladder  cells  found  in  the  urine,  as 
by  this  time  the  superficial  layers  have  been  to  a  marked  extent  destroyed. 
In  addition,  in  chronic  cystitis,  the  cells  present  are  found  filled,  with  fatty 
granules  of  various  sizes,  and  many  of  them  are  in  a  state  of  partial  dis- 
integration. 

The  deepest  layers  of  the  bladder  are  composed  of  columnar  cells  which  are 
rarely  found  in  the  urine,  save  in  ulcerative  processes,  in  tumors,  and  in  cases 
of  intense  inflammation. 

(e)  Epithelia  from  the  Ejaculatory  Ducts  and  the  Seminal  Vesi- 
cles.— Epithelia  from  the  ejaculatory  ducts  are  elongated  cylindrical  and  cili- 
ated, though  the  cilia  may  be  broken  off.  These  cells  are  easily  recognized  by 
their  shape. 

Epithelia  from  the  seminal  vesicles  are  colunniar,  nouciliated,  and  some- 
times contain  a  yellow  pigment.  They  are  rather  larger,  broader  and  less 
ri'gular  than  the  epithelia  from  the  ejaculatory  ducts. 

Epithelia  from  the  ejaculatorv  ducts  and  from  the  seminal  vesicles  occur 
in  the  urine  in  cases  of  seminal  vesiculitis,  and  vesiculo-prostatitis.  They  are 
often  associated  with  pus  cells,  urethral  cells  and  prostatic  cells. 


104  THE   URINE 

(/)  Prostatic  EriTiiELiA. — There  are  two  types  of  epithelia  from  the 
prostate.  The  ducts  of  the  gland  are  lined  with  columnar,  tlie  acini  with  cu- 
hoidal  cells.  The  cuboidal  epithelia  are  twice  the  size  of  pus  cells,  and  are 
identical  with  the  epithelia  from  the  ureter.  Prostatic  epithelia,  however,  do 
not  occur  in  association  with  renal  and  pelvic  cells.  They  are  apt  to  be  asso- 
ciated with  pus,  with  spermatozoa  and  amyloid  bodies  from  the  prostate. 

(g)  Epithelia  fkom  the  Urethka. — The  stratified  lining  of  the  urethra 
is  represented  in  the  urine  by  cells  of  a  great  variety  of  shapes.  The  super- 
ficial cells  are  present  in  the  milder  grades  of  inflammation  and  are  squamous 
or  cuboidal.  They  are  always  smaller  than  the  bladder  cells  and  larger  than 
any  other  cells  from  the  tract.  The  deeper  layers  of  the  urethra,  with  their 
smaller  cylindrical  cells,  are  less  frequently  represented,  appearing  in  the 
deeiDer  and  more  chronic  processes.  In  such  cases  they  show  numerous  fat 
granules  and  are  often  fragmented. 

(^h)  Epithelia  from  the  Vagina. — The  largest  cells  in  the  urine  come 
from  the  vagina.  Usually  the  superficial  squamous  cells  are  represented ;  in 
fact,  they  are  present  in  the  urine  of  most  women  in  health.  In  vaginitis,  they 
are  increased  in  number,  accompanied  by  bacteria,  mucus  and  pus.  These  cells 
may  be  found  wrinkled  or  folded  and  show  fine  granules  or  fat  globules. 

The  cuboidal  epithelia  from  the  middle  strata  of  the  vagina  are  found  in 
severe,  especially  in  chronic,  vaginitis ;  and  may  contain  fat  granules.  The  col- 
umnar epithelia  from  the  deepest  layers  are  seen  only  in  very  extensive  ulcera- 
tions. All  vaginal  cells  are  larger  than  those  of  the  corresj)onding  layers  of  the 
bladder. 

(i)  Epithelia  from  the  Uterus. — These  do  not  often  occur  in  the  urine. 
They  cannot  be  differentiated  from  urethral  epithelia.  The  mucosa  of  the 
uterus  itself  sheds  cylindrical  ciliated  epithelia,  the-  presence  of  which  indicates 
endometritis. 

4.  Urinary  Casts. — Three  views  are  held  as  to  the  fonnation  of  casts:  (1) 
That  they  are  the  result  of  the  disintegTation  of  the  epithelium  of  the  renal 
tubes,  the  resulting  products  being  packed  into  molds  by  the  pressure  of  the 
urine  and  at  last  forced  out.  (2)  That  they  consist  of  a  morbid  secretion  from 
the  renal  epithelium  similarly  caked  into  molds.  (3)  That  they  are  formed 
from  the  coagulable  elements  of  the  blood  (serum)  albumin  which  gain  access 
to  the  renal  tubes  through  pathological  lesions  of  the  latter,  and  that  any  de- 
tached portions  of  the  tubules  become  entangled  in  this  coagulable  product, 
assisting  to  form  the  mold  which  afterwards  appears  in  the  urine.  This  latter 
view  is  the  one  most  generally  accepted. 

Casts  may  be  conveniently  divided  for  purj^oses  of  study,  into  ten  kinds, 
viz. : 

(a)  Hyaline  casts,  whose  origin  and  nature  are  still  a  matter  of  discussion, 
appearing  as  narrow  hyaline,  broad  hyaline  and  composite  casts. 


MICROSCOPICAL   EXAMINATION 


105 


(h)  Granular  casts,  iiiadc  iij)  oi'  a  hyaline  basis,  (*<»ii1;iiiiiiia,'  lirainilcs  of  dis- 
iiitcg-rated  leucocytes,  and  red  and  epithelial  cells. 

(c)  Epithelial  casts,  made  of  unchanged  anatomical  elements,  including 
red  blood  cor})uscles,  leucocytes,  eiDithelial  cells,  or  hactcria. 

((I)   ]jlood  casts.  {h)   Amyloid  casts, 

((')    Pus  casts.  (i)   Mixed  casts. 

(/')   Fatty  casts.  (j)   Cylindroids. 

{(j)   Waxy  casts. 

(a)  Hyai-ine  Casts  (Fig.  104). — These  are  the  pale  structures  of  variable 
but  usually  considerable  length,  sometimes  very  difficult  to  detect  in  the  sedi- 
ment. Sometimes  they  are  transparent  and  free  from  granules;  more  fre- 
quently they  present  fine  granulations  of  a  very  light  color.  They  may  also 
have  a  few  drops  of  fat  or  fragments  of  epithelium  adhering  to  the  surface. 
The  origin  of  the  hyaline  cast  has  been  variously  explained  as  a  result  of  secre- 
tion from  the  epithelia  of  the  kidney,  or  as  a  coagulation  of  the  albumin  or  its 
derivatives  excreted  with  the  urine.  In  support  of  the  latter  view  it  is  stated 
that  they  are  found  only  when  the  urine  is  albuminous,  or  has  lately  been  so. 
The  occurrence  of  albumin  and  casts  may  not  be  simultaneous. 

It  is  a  mistake  to  regard  the  presence  of  very  small  narrow  hyaline  casts  as 
of  no  great  importance,  as  is  sometimes  done,  for  they  are  often  the  chief 
urinary  sign  of  the  existence  of  a  very  grave  disease  of  the  kidneys,  namely, 
chronic  interstitial  nephritis  in  which  the  albuminuria  may  be  slight  or  absent. 


Fig.   105. — Granular  Casts.     (Ogden.) 

Fig.  104. — Hyaline  Casts.  ,  ,  i  i  x 

a,  granular  cast.  c,  coarsely  granular  cast. 

b,  finely  granular  cast.  d,  brown  granular  cast. 

(7;  )  GkAXULAU  Casts  (  Fi"".        ^'  granular  cast  with  normal  and  aianormal  blood  adherent. 
„        '  ^  f,  granular  cast  with  renal  cells  adherent. 

JO.)  ). 1  Ins      lorm      01      casts,        g^  granular  cast  with  fat  and  a  fatty  renal   cell  adherent. 

resulting    from    the    metamor- 
phosis of  anatomical  elements,  such  as  epithelium,  pus,  or  blood,  is  found  in 
the  urine  in  great  variety.      The  casts  vary  much  in  shape  and  appearance 
and   are   most   often   seen    in    fragments.     They     are    irregular,    in    both    fine 
and  coarse  outline,  with  ragged  ends,  the  granules  varying  from  those  which 


106 


THE   URINE 


require  the  highest  powers  to  discover  to  a  relatively  coarse  size  which  gives  it8 
name  to  the  cast.  They  are  of  various  colors — yellow,  gray,  or  brown — and 
may  have  scattered  over  their  surfaces  epithelium,  leucocytes,  fat  globules,  or 
fatty  crystals.  Granular  casts  have  generally  been  regarded  as  evidence  of 
pathological  changes  in  the  kidney  of  a  chronic  degenerative  nature. 

(c)  Epithelial  Casts  (Fig.  106). — This  form  is  due  to  patliological  con- 
ditions wdiich  cause  the  exfoliation  of  the  renal  epithelium.  At  times  this  is 
thrown  off  intact  for  short  distances,  resulting  in  cylinders  with  lumens ;  or 
the  cast  may  be  solid,  the  body  being  hyaline  and  the  epithelia  adherent  to  it. 
The  cells  when  seen  imder  the  microscope  appear  more  or  less  swollen  and  gTan- 
ular,  with  ill-defined  margins.  Sometimes  the  epithelial  cells  appear  as  rows 
or  patches  scattered  over  the  surface  of  the  cast.  In  other  cases  the  epithelia 
have  undergone  degeneration  and  present  dots  of  fat,  significant  of  chronic 
inflammation  of  the  kidney  and  consequent  fatty  change.  Finally,  some  casts 
consist  of  epithelial  cells  alone,  glued  together.  Casts  of  epithelial  variety  are 
usually  of  medium  size  and  length,  refracting  light  to  a  marked  degree  and 
therefore  easy  to  find  with  the  microscope.  They  resist  the  action  of  chemical 
reagents  more  than  most  varieties.  Epithelial  casts  always  signify  inflamma- 
tion of  the  kidney  and  are  therefore  of  gTeat  diagnostic  worth. 


Fig.  107. — Blood  Casts,  Composed  Wholly  of 
Red  or  W'hite  Corpuscles  or  Hyaline  Sub- 
stance Covered  with  Blood  Corpuscles. 


Fig.   106. — Epithelial  Casts. 

(d)  Blood  Casts  (Fig.  107). — 
Blood  casts  appear  in  the  urine  under 
conditions  which  cause  hemorrhage 
in  the  renal  tubules.  The  corpuscles 
may  be  well  preserved  and  glued  to- 
gether to  form  perfect  molds  of  the  renal  tubes,  usually  short  and  of  uniform 
diameter  with  rounded  ends. 

These  casts  are  found  in  nephritis,  especially  acute,  in  hemorrhages,  acute 
renal  congestion  and  hemorrhagic  infarction  of  the  kidney.  They  do  not  in 
themselves  furnish  positive  proof  of  organic  renal  disease,  but,  on  the  other 
hand,  blood  casts  are  positive  evidence  of  renal  hemorrhage.  These  casts  are 
among  the  rarer  kinds  and  are  usually  hard  to  find,  since  a  large  sediment  of 
blood  corpuscles  is  apt  to  accompany  them  and  obscure  the  microscopic  field. 


MICKOSCOPICAL   EXAMINATION 


107 


(e)   Pus  Casts   (Fig.   108). — Casts  composed  altogether  of  pus  are  very 
rare.     Compound  casts,  however,  may  present  a  few  corpuscles  here  and  there 


Fig.  108.— Pus  Casts. 


Fig.  109. — Fatty  and  Other  Casts.     (Ogden.) 

1,  epithelial  cast.  S,  pus  cast. 

2,  blood  cast.  4>  fatty  cast. 
5,  fatty  cast  with  compound  granules  and  fatty 

renal  cells  adherent  (crystals  of  the  fatty  acid 
protruding) . 


on  their  surface.  They  signify  puru- 
lent intlammation  in  the  kidney  itself 
— i.  e.,  pyonephritis  or  pyonephrosis. 
Bacteria  are  present  in  pus  casts. 

(/)  Fatty  Casts  (Fig.  109). — Oil  globules  are  often  found  adherent  to 
many  varieties  of  casts,  whereas  others  are  frequently  seen  which  seem  wholly 
made  up  of  fatty  material, 
including  crystals  of  the  fat- 
ty acids.  These  fatty  acids 
indicate  fatty  changes  in  the 
kidneys  and  are  found  in 
their  most  typical  form  in 
the  large  white  kidney. 
They  suggest  pathological 
states  of  the  kidney  whose 
chief  feature  is  chronicity, 
since  they  are  the  result  of 
complete  destruction  of  the 
cell  protoplasm,  which  is  re- 
placed by  fatty  elements. 

(fj)  Waxy  Casts  (Fig. 
210). — Waxy  casts  reseni- 
l)lo  somewhat  hyaline  easts. 
Tliey  are  more  refractive, 
and  are  yellow  or  grayish- 
3'ellow  in  color  and  differ 
fnrthermore  in  presenting  a 
cloudy  appearance.  Unlike 
hyaline  casts,  they  are  not 
attacked  by  acetic  acid. 
Tliongh  they  resemble  amy- 


FiG.  110.  —  Types  of  Casts  with  a  Waxy  Matrix  from  a 
Case  of  Subacute  Parenchymatous  Nephritis.  ("Wood ) 
Some  of  the  casts  are  quite  transparent,  others  are  granular 
at  one  end  and  clear  at  the  other.  Some  are  composed  partly 
of  granular  matter  and  partly  of  waxy  material.  The  casts 
vary  greatly  in  .size,  but  are  all  drawn  to  the  same  scale. 
One  very  small  cast  in  the  center  is  of  the  hyaline  variety. 


108 


THE   ITRINE 


loid  casts  in  appearance,  yet  their  presence  does  not  indicate  amyloid  disease 
of  the  kidney.  It  is  possible  that  they  were  originally  hyaline  casts  which  have 
remained  in  the  nriniferons  tubules  for  a  long  time  and  have  there  undergone 
certain  chemical  changes  analogous  to  "  amyloid  metamorphosis." 

(h)  Amyloib  Casts. — Amyloid  casts  resemble  in  appearance  waxy  casts. 
They  can  be  differentiated,  however,  by  the  addition  of  dilute  iodopotassic 
iodid  solution  (Lugol's  solution),  when  they  assume  a  mahogany  color  which 
changes  to  a  dirty  violet  uj^on  the  addition  of  dilute  sulphuric  acid.  Waxy 
casts  do  not  give  this  reaction.  The  presence  of  amyloid  casts  is  indicative  of 
amyloid  degeneration  of  the  kidney. 

(i)  Mixed  Casts  (Fig.  110). — The  various  kinds  of  casts  are  sometimes 
found  in  the  same  specimen,  depending  on  the  stage  of  pathological  process  in 
the  kidney. 

(_/")  Cylindroids  (Fig.  111). — In  addition  to  the  varieties  of  casts  men- 
tioned, the  urine  may  contain  what  are  called  cylindroids.      These  are  long, 

wavy,  ribbonlike  structures, 
Avhich  often  divide  and  sub- 
divide at  their  ends.  The  ends 
may  be  folded  or  twisted. 
They  are  pale,  colorless  and 
of  greater  length  than  casts, 
and  seldom  have  cells  adher- 
ent to  them.  They  appear 
flat  and  do  not  give  the  im- 
pression of  being  solid  struc- 
tures like  the  true  renal  casts. 
It  seems  probable,  however, 
that  these  cylindroids  come 
from  the  renal  tubules.  They 
occur  in  nephritis,  cystitis  and 
in  renal  congestion,  and  may 
be  present  in  urine  which 
contains  no  albiunin.  They 
are  not  characteristic  of  kid- 
ney disease,  but  rather  of  irritations  of  the  lower  urinary  tract,  Avhich  have 
extended  to  the  kidney. 


Fig.  111. — Cylindroids  or  False  Casts.     (After  Peyer.) 


ISToTE. — To  find  casts  Avith  the  least  delay,  the  urine  should  be  voided 
freshly,  immediately  centrifuged  for  three  minutes,  and  four  to  six  drops  of 
the  sediment  taken  up  with  the  pipette  and  placed  on  a  perfectly  clean  slide, 
a  cover  glass  laid  on,  the  excess  urine  removed  by  blotting  paper,  and  the  speci- 
men examined  with  a  quarter-inch  objective  in  not  too  bright  a  light.     Fly  aline 


MICROSCOPICAL  EXAMINATION  109 

casts  may  be  overlooked,  but  wlien  the  focus  has  been  carefully  adjusted,  if 
the  field  be  darkened  gradually  till  perhaps  one  third  of  the  illumination  is 
cut  off,  and  the  slide  be  moved  slowly  about,  the  contents  of  the  field  arc  viewed 
in  different  liiihts  and  the  outlines  or  shadows  of  the  hyaline  casts  may  be  de- 
tected. If  doubt  exists  as  to  the  nature  of  a  cast,  slight  pressure  on  the  cover 
glass  will  cause  currents  under  it  and  cause  the  cast  to  turn. 

5.  Shreds. — Under  the  Microscopical  Examination  of  Sediment,  something 
should  be  said  of  shreds  voided  with  the  urine  in  an  acute  or  chronic  process 
of  the  genito-urinary  tract.  If  they  are  derived  from  destructive  processes  in 
the  bladder,  prostate,  or  the  kidney,  they  contain  connective  tissue.  Shreds 
not  due  to  destructive  lesions  are  the  result  of  subacute  or  chronic  urethritis, 
prostatitis,  pyelitis,  or  cystitis. 

Several  varieties  of  shreds  may  be  distinguished:  (1)  Pus  shreds,  (2) 
mucous  shreds,  (3)  muco-pus,  and  (4)  epithelial  shreds.  The  characteristics 
of  these  four  varieties  are  sufficiently  well  marked  to  be  readily  recognized  by 

the  microscope. 

Examination  of  Sheeds. — They  are  carefully  removed  from  the  urine 
with  a  platinum  loop  and  spread  upon  a  slide  with  a  few  drops  of  water,  teased 
apart  with  a  needle  if  they  are  thick,  and  a  cover  glass  placed  over  the  speci- 
men, after  which  their  composition  can  be  determined.  Eor  a  bacteriological 
examination,  the  shreds  can  be  stained  like  tissue  sections.  For  this  purpose 
the  following  method  can  be  employed. 

1.  Fix  with  alcohol  and  ether  for  ten  minutes. 

2.  Stain  for  one  or  two  minutes  with  Unna's  polychrome  methylene  blue. 

3.  Wash  in  distilled  water.     Dry. 

4.  Dehydrate  for  a  few  seconds  in  ninety-fivc^per-cent  alcohol.  Dry  with 
filter  paper. 

5.  Clear  in  xylol  or  in  clove-thyme  mixture. 

6.  Mount  in  balsam. 

Massage  Pkoducts  in  the  Urine. — After  massage  of  the  prostate  and 
vesicles,  certain  products  may  be  voided  with  the  urine  and  these  should,  there- 
fore, be  mentioned  under  Examination  of  Sediment. 

In  chronic  inflammations  and  infections  of  the  prostate  and  vesicles,  the 
urine  contains  many  pus  cells  and  red  blood  cells,  together  with  shreds.  In 
seminal  vesiculitis  after  massage,  large  masses  of  the  secretion  of  the  seminal 
vesicles,  together  with  inflammatory  detritus,  are  thrown  off,  looking  like  meal 
in  the  water,  and  sometimes  like  a  thick  white  lump.  These  are  often  so  large 
and  thick  as  to  block  the  urethra  for  an  instant.  In  addition  to  these  elements, 
the  urine,  after  massage  of  the  prostate  and  vesicles,  very  frequently  contains 
other  products,  the  significance  and  pathology  of  which  are  not  quite  so  clear. 
1  call  them  tapioca,  sugar  granules,  skin  flakes,  and  snowflakes. 


110  THE   URINE  ' 

*S'a</o  Bodies. — Sago  bodies  consist  of  round  or  ovoid  masses,  of  a  semi- 
opaqiie,  yellowish-white,  colloid  material,  varying  in  size  from  a  barley  corn 
to  a  lentil.  Under  the  microscope  they  are  found  to  consist  of  homogenous  col- 
loid matrix,  in  -which  are  imbedded  motionless  spermatozoa. 

Tissue  Shreds. — Tissue  shreds  are  never  found  in  the  urine  under  normalj|i 
conditions.  They  are  always  evidence  of  tissue  destruction  or  deep-seated  in-| 
flammation,  and  are  found  in  ulcerative  conditions,  in  tuberculosis,  trauma,! 
tumors,  and  abscess  of  the  prostate.  I 

Sugar  Granules. — These  bodies  resemble  granules  of  melting  sugar;  they  i 
are  much  smaller  than  sago  bodies,  of  the  same  transparency  and  light-yellow 
color.     They  are  often  present  in  large  quantity,  falling  rapidly  to  the  bottom 
and  dissolving  in  a  few  minutes.     Microscopically  they  are  homogenous,  struc-  ' 
tureless  bodies,  consisting  of  a  highly  refractive  matrix,  in  which  there  are  few  . 
or  no  spermatozoa  and  cellular  elements. 

Shins. — These  are  delicate,  opaque,  white,  skin  or  membranelike  fragments. 
They  are  composed  of  thickened  inspissated  vesicular  secretion  which  has  lain 
for  a  considerable  time  in  the  organ.  They  represent  a  deposit  of  secretion 
that  has  been  formed  in  some  of  the  recesses  of  the  seminal  vesicles  and  has 
been  loosened  and  pushed  through  the  ejaculatory  ducts  by  massage.  Skins 
are  found  especially  abundant  in  men  who  have  abstained  from  sexual  inter- 
course for  a  long  time,  especially  if  a  chronic  catarrhal  condition  is  present. 
Snowflakes  represent  a  similar  accumulation  that  has  lasted  but  a  short  time 
and  are  much  lighter  and  more  flaky. 

V.   BACTERIOLOGY   OF   THE   URINE 

Although  germs  have  been  found  in  the  urine  of  healtliy  persons,  the  ma- 
jority of  investigators  state  that  the  urine  in  health  is  sterile,  provided  it  be 
obtained  by  sterile  instruments  and  under  proper  precautions.  The  blood  and 
the  various  tissues  and  organs  of  the  body  also  are  said  to  be  free  from  bacteria 
in  health.  During  and  after  infectious  diseases,  such  as  typhoid  fever,  gi'ip, 
pneumonia,  and  septic  infection,  germs  are  often  found  in  the  urine. 

Inasmuch  as  the  urethra  is  always  inhabited  by  saprophytic  bacteria,  the 
urine  flowing  from  the  meatus  can  hardly  be  expected  to  be  absolutely  sterile, 
all  the  more  so  because  it  is  often  mixed  with  bacteria  from  the  surface  of  the 
glans  and  prepuce  in  men  and  from  the  vulva  in  women.  Therefore,  an  or- 
dinary specimen  of  urine  freshly  passed  even  in  health  will  certainly  contain 
some  bacteria. 

Experiments  have  proved  that  the  urine  possesses  bactericidal  properties 
in  health  and  shown  that  the  absence  of  bacteria  from  normal  persons  may  mean 
that  the  germs  have  been  destroyed  by  virtue  of  this  property.  It  has  also 
been  shown  that  fresh  urine  has  the  property  of  destroying  the  anthrax,  cholera 


PLATE    II 


Fig.  1. — Staphylococcus  pyogenes 

AUREUS. 


Fig.  2. — Streptococcus  pyogenes. 


Fig.  3. — Bacillus  coli. 


BACTERIA   FOUND   IN   THE   URINE. 


BACTERIOLOGY   OF   THE   URINE  HI 

and  less  constantly  tlic  typhoid  bacilli,  by  virtue  of  the  presence  of  the  acid- 
potassiiini  phosphate.  If  the  urine  is  neutralized  by  addition  of  alkalies,  its 
bactericidal  property  tends  to  disappear.  Possibly  the  chlorids  or  some  other 
constituents  may  also  act  as  antagonists  of  the  bacteria. 

In  disease,  the  bacteria  which  may  occur  in  the  urine  are  many.  A  few 
of  them,  however,  are  of  importance,  as  they  play  a  prominent  role  in  the  causa- 
tion of  urinary  affections.  These  important  special  germs  are  the  gonococcus, 
the  tubercle  bacillus,  the  colon  bacillus,  the  Streptococcus  pyogenes,  and  the 
Staphylococcus  pyogenes  aureus  and  albus,  the  Bacillus  proteus  of  Ilauser,  the 
typlioid  bacillus,  which  occurs  in  the  urine  in  typhoid  fever,  and  rarely  the 
Bacillus  pyocyaneus.  Still  more  rarely  the  pneumobacillus  of  Fraenkel  is 
found.  In  certain  infectious  diseases,  such  as  anthrax,  plague,  etc.,  the  cor- 
responding germs  have  been  found  in  the  urine.  With  the  exception  of  the 
last-mentioned  germs,  which  are  rarely  found  in  the  urine,  all  the  above-men- 
tioned germs  have  been  known  to  produce  cystitis.  The  following  is  a  list  of 
germs  concerned  in  the  causation  of  suppurative  inflammations  of  the  kidney, 
ureter,  and  bladder  in  the  order  of  frequency : 


These  may  be  saprophytes  in  the 
urethra,  especially  in  the  female. 


1.  The  colon  bacillus, 

2.  The  Bacillus  proteus  vulgaris, 

3.  The  Staphylococcus  pyogenes, 

4.  The  Streptococcus  pyogenes, 

5.  The  tubercle  bacillus, 

6.  The  gonococcus. 

7.  The  typhoid  bacillus. 

8.  The  Bacillus  pyocyaneus  (rare). 

The  gonococcus  is  found  in  the  urine  in  gonorrheal  infections  of  the 
urinary  tract  and  the  tubercle  bacillus  in  tuberculous  infections.  The  germs 
of  suj)puration,  such  as  the  streptococcus  and  staphylococcus,  and  the  colon 
and  proteus  bacillus  are  found  in  suppurative  conditions  of  the  kidneys,  pelvis, 
ureters,  etc. 

Bacteria  in  the  Urine 

Mode  of  Entrance. — Germs  may  be  introduced  from  the  urethra  or  from 
the  outside  into  the  bladder  either  by  unclean  instruments  or  simply  by  pushing 
germs  present  in  the  urethra  into  the  bladder  with  sterile  instruments.  A 
urethral  infection  also  may  be  transmitted  by  continuity  to  the  bladder,  where 
the  germs  will  then  appear  in  the  urine.  If  the  bladder  is  sterile  and  the 
urine  therein  free  from  germs  and  if  the  urethra  is  infected,  the  urine,  of 
course,  may  wash  numerous  germs  from  the  urethra  into  the  vessel  in  which  the 
sample  is  collected.     These  modes  of  infection  of  the  urine  are  practically  self- 


112  TTTE    TRfXE 

evident.  Infection  of  the  urine  in  Hie  liladder  ]>\  germs  transmitted  from  the 
normal  urethra  does  not  occur  in  man,  owing  t(^  the  fact  that  the  vesical  sphinc- 
ter shuts  off  the  bladder  from  the  urethra.  On  the  otlier  hand,  in  women,  hhid- 
der  infection  may  occur  through  the  healthy  urethra. 

In  addition  to  an  infection  from  the  urethra  upward,  the  urine  may  become 
contaminated  also  by  the  entrance  of  bacteria  into  tlie  kidney  through  the  cir- 
culation (especially  of  the  tubercle  bacillus),  and  by  the  passage  of  bacteria 
into  the  bladder  through  the  intestinal  wall. 

The  question  of  a  descending  infection  has  been  demonstrated  both  experi- 
mentally and  clinically.  It  is  difficult  to  understand  at  first  how  bacteria  can 
infect  the  kidney  from  the  bladder  when  the  stream  of  urine  apparently  tends 
to  prevent  this  by  opposing  the  ascent  of  the  germs.  Anim'al  experiments, 
however,  have  shown  that  under  certain  conditions,  the  contents  of  the  bladder 
regurgitate  into  the  pelvis  of  the  kidney.  When  the  germs  reach  the  pelvis, 
they  may  enter  through  the  lymphatics  of  the  kidney,  less  frequently  through 
the  urinary  tubules,  and  more  rarely  through  the  capillaries  of  the  kidney. 
The  entrance  of  germs  from  the  blood  through  the  kidneys  into  the  urine  has 
been  repeatedly  demonstrated.  Germs  may  enter  the  bladder  directly  from  the 
intestine  in  cases  in  wdiich  the  bladder  is  damaged,  or  from  the  intestine  into 
the  blood  and  thence  into  the  kidney. 

The  Gonococcus  in  the  Urine. — To  avoid  repetition,  we  have  grouped  all 
data  on  the  gonococcus  in  the  chapter  on  the  Examination  of  Urethral  Dis- 
charges. 

The  gonococcus  is  usually  found  in  the  urine  in  urethritis,  sometimes 
in  prostatitis  and  vesiculitis  after  massage,  and  occasionally  in  cystitis,  pyelitis 
and  pyelo-nephritis  in  ascending  infections  of  gonorrheal  origin.  The  germ  is 
much  more  difficult  to  detect  in  the  urine  than  in  smears  of  discharge.  In  the 
urine,  it  is  always  accompanied  by  pus  and  is  to  be  looked  for  within  the  cyto- 
plasm of  the  pus  cells,  or  upon  the  epithelia  of  the  sediment.  The  methods  of 
obtaining  and  precipitating  the  sediment  for  such  examination  has  been  given 
in  the  preceding  pages. 

The  Tubercle  Bacillus. — The  tubercle  bacillus  occurs  in  the  form  of  a  small 
rod,  one  quarter  to  one  half  as  long  as  the  diameter  of  a  red  blood  corpuscle. 
The  rods  are  delicate,  straight,  slightly  bent  or  curved,  and  somewhat  beaded. 
They  occur  either  singly  or  in  groups,  especially  in  the  form  of  tufts  which 
are  commonly  found  in  the  urine.  At  times  they  are  found  also  within  the 
body  of  the  pus  cell.  In  some  specimens,  the  ends  of  the  rods  are  somewhat 
clubbed  or  branched,  or  present  swellings  at  different  points.  In  stained 
preparations,  the  bacilli  show  alternation  of  stained  and  colorless  portions. 

Method  of  Staining. — The  detection  of  the  tubercle  bacillus  depends 
upon  its  characteristic  behavior  toward  anilin  dyes  and  decolorizing  agents. 
The  penetrating  power  of  the  dye  used  must  be  increased  by  the  addition  of 


PLATE    III 


Fig.  1. 


Fig.  2. 


BACTERIA,  SHOWING  THE  OPSONIC  ACTION  INCREASED  BY  THE  PROPER 
ADMINISTRATION   OF   BACTERIAL  VACCINES. 


Fig.  1. — Tubercle  Bacilli  in  Sputum.  The 
tul:)ercle  bacilli  are  stained  red  with  carbol- 
fuchsin.  At  A  the  bacilli  are  inside  the 
leukocytes,  showing  phagocytosis,  or  that 
the  bacteria  have  been  prepared  for  inges- 
tion by  the  opsonins.  B  shows  the  bacilli 
outside  the  leukocytes  not  prepared  for  in- 
gestion by  the  opsonins. 


Fig.  2. — Gonococci  in  Urethral  Pus.  The 
gonococci  are  stained  with  methylene  blue. 
At  A  the  cocci  are  inside  the  leukocytes, 
showing  phagocytosis,  or  that  the  bacteria 
have  been  prepared  for  ingestion  by  the 
opsonins.  B  shows  cocci  outside  the 
leukocytes  not  prepared  for  ingestion  by  the 
opsonins.  C  shows  the  cocci  haAing  prob- 
ably been  ingested  by  the  white  blood- 
corpuscles,  but  the  toxins  of  the  gonococci 
have  destroyed  the  leukocytes. 


BACTEEIOLOGY   OF    THE   URINE  113 

either  carbolic  acid  or  anilin  oil  and  by  the  application  of  heat.  Once  stained 
ill  this  way,  the  bacilli  resist  acids,  and  npon  this  depends  the  differentiation 
frmii  other  bacteria  in  the  same  specimen. 

Ziehl-Ncclscn  Method. — This  is  the  method  in  common  nse  for  staining  tu- 
lierele  bacilli  in  the  nrine. 

Tlie  sediment  is  obtained  in  as  concentrated  a  form  as  possible,  and  spread 
in  a  thin  layer  npon  a  slide  or  cover  glass  and  allowed  to  dry  in  the  air.  The 
])reparation  is  then  fixed  in  the  nsnal  way  in  the  flame  of  a  Bunsen  bnrner. 
The  s})ecimen  is  then  covered  with  some  filtered  Ziehl-iSTeelsen  carbol-fuchsin 
solution  (five-per-cent  aqneons  solution  carbolic  acid,  ninety  parts;  saturated 
alcoholic  solution  of  fuchsin,  ten  parts)  and  held  over  the  flame  of  a  Bunsen 
burner,  allowing  the  solution  to  steam  for  one  or-  two  minutes  without  bringing 
it  to  the  boiling  point.  The  specimen  is  then  washed  in  a  stream  of  running 
water  and  immersed  in  five-per-cent  sulphuric  or  thirty-per-cent  nitric  acid. 
The  film  turns  yellow  or  brown,  but,  on  washing  again  in  water,  the  red  color 
reappears.  The  operation  is  then  repeated  until  only  a  very  faint  tinge  is  left 
and  no  more  of  the  stain  is  given  off.  The  specimen  is  now  washed  for  from 
ten  to  fifteen  minutes  in  strong  (ninety-five  per  cent)  alcohol,  folloAved  by  rins- 
ing in  water.  In  staining  a  urine  specimen,  the  use  of  alcohol  is  an  important 
step  as  a  means  for  excluding  the  smegma  bacillus,  which  is  decolorized  by 
alcohol.  The  specimen  is  now  covered  with  a  weak,  watery  solution  of  methy- 
lene blue,  which  is  allowed  to  remain  for  from  one  to  two  minutes.  After  wash- 
ing and  drying,  the  specimen  is  ready  for  examination  with  an  immersion  lens. 

Differentiation. — The  tubercle  bacillus  may  be  confounded  morphologic- 
ally with  two  different  germs :  the  smegma  bacillus  and  the  leprosy  bacillus. 

The  smegma  bacillus  is  most  often  confounded  with  the  tubercle  bacillus. 
It  occurs  in  the  decomposing  secretion  around  the  genitals.  In  obtaining  speci- 
mens of  urine  for  examination  for  tubercle  bacilli,  care  must  be  taken,  first,  to 
wash  the  external  genitals  with  soap  and  hot  water,  so  as  to  remove  any  smegma 
germs,  and  then  to  draw  off  the  urine  with  a  sterilized  catheter.  If,  in  addi- 
tion to  these  precautions,  the  specimens  are  washed  in  alcohol  after  decolorizing, 
as  previously  mentioned,  there  is  very  little  danger  of  error  in  the  microscopical 
diagnosis. 

The  lepra  hacillus  resembles  the  tubercle  bacillus  both  in  shape  and  stain- 
ing properties,  but  is  somewhat  shorter,  thicker,  and  stains  unevenly.  It  oc- 
curs, however,  so  rarely,  that  its  differentiation  from  the  tubercle  bacillus  need 
not  be  discussed  here. 

Animal  Inoculation. — In  case  of  doubt  as  to  the  nature  of  the  bacillus  and 
in  instances  in  which  repeated  examinations  of  urinary  sediments  do  not  show 
any  tubercle  bacilli,  although  clinically  tuberculosis  is  suspected,  recourse  may 
lie  had  to  inoculation  of  animals  and  to  cultures  on  artificial  media.  The  ma- 
terial should  be  introduced  subcutaneously  or  into  the  peritoneum,  the  former 


114  THE    URINE 

method  taking  from  four  to  ten  weeks,  the  latter  from  ten  to  twenty  days  for 
tnbereular  lesions  to  develop  when  tubercle  bacilli  are  present.  If  smegma 
bacilli  only  are  present,  no  lesions  develop.  At  tlie  end  of  the  time  stated,  an 
antopsy  is  performed  upon  the  animal,  and  the  site  of  puncture,  the  peritoneum, 
the  lungs,  and  other  organs  are  examined  for  tubercles. 

The  Colon  Bacillus. — The  colon  bacillus  occurs  normally  in  the  intestine 
of  man,  bovines,  dogs,  and  other  domestic  animals.  Its  close  resemblance  to 
the  typhoid  bacillus  makes  it  an  object  of  interest.  Certain  features,  however, 
distinguish  it  from  the  typhoid  bacillus,  and  it  is  regarded  as  a  distinct  species 
of  germ.  The  colon  bacillus  may  under  favorable  conditions  produce  serious 
disease.  It  is  the  cause  of  local  suppuration  in  a  gTeat  variety  of  organs,  and 
also  produces  at  times  general  septic  infection.  The  colon  bacillus  plays  an 
important  role  in  urinary  affections,  as  it  is  one  of  the  chief  germs  concerned 
in  the  causation  of  cystitis,  and  is  found  also  in  the  urine  and  the  purulent 
sediment  in  cases  of  infection  of  the  kidney,  the  pelvis,  and  ureter. 

MoKPHOLOGY. — The  colon  bacillus  occurs  in  the  form  of  rods,  with  rounded 
ends,  which  may  vary  in  two  directions :  they  may  be  either  so  short  as  to  ap- 
pear almost  like  cocci  or  so  long  as  to  resemble  threads.  ISTo  spores  have  been 
demonstrated,  but  flagella  may  be  shown  by  Loeffler's  method.  It  is  motile  in 
most  cases,  but  often  its  movements  are  very  slow. 

Staining  Properties. — It  stains  with  ordinary  anilin  dyes  and  is  decolor- 
ized by  Gram's  method. 

Streptococcus  Pyogenes. — The  Streptococcus  pyogenes  is  the  cause  of  local 
inflammatory  and  suppurative  processes  and  of  general  infections  such  as  sep- 
ticemia. In  the  urinary  tract  it  is  found  in  inflammatory  conditions  of  the 
urethra,  bladder,  kidney,  pelvis,  and  ureter,  either  alone  or  more  generally  in 
comjjany  with  other  germs  of  suppuration,  as  the  tubercle  bacillus,  with  which 
it  is  very  frequently  associated. 

The  Streptococcus  pyogenes  occurs  in  the  form  of  chains  of  minute  round 
or  oval  cocci  resembling  strands  of  beads.  Sometimes  two  or  more  cells  in  the 
chains  coalesce  to  form  a  somewhat  longer  segment.  The  chains  may  be  short, 
consisting  of  a  few  cells,  or  very  long.  Sometimes  the  cocci  composing  a  chain 
divide  simultaneously,  so  that  a  chain  of  diplococci  may  be  seen.  The  strepto- 
coccus stains  easily  with  anilin  dyes  and  usually  stains  with  Gram's  method. 

Staphylococcus  Pyogenes  Aureus. — The  Staphylococcus  aureus  is  the  most 
common  of  the  germs  of  suppuration.  It  occurs  in  abundance  everywhere,  and 
is  the  usual  cause  of  wound  infection.  It  is  present  in  the  normal  as  well  as 
the  diseased  urethra,  is  frequently  found  in  the  bladder  in  cystitis,  and  plays 
a  prominent  part  in  infections  of  the  kidney,  either  alone  or  accompanying 
other  germs,  as  the  colon  bacillus,  the  streptococcus,  etc.  In  tuberculosis  of  the 
urinary  tract,  it  is  often  present  as  a  complicatory  organism,  along  with  other 
germs  of  suppuration. 


BACTERIOLOCiY    OV    TITE    URTNE  115 

Tt  oocurs  in  the  form  of  round  or  oval  cocci  arranged  typically  in  clusters, 
Itiit  often  in  pairs.  In  preparations  from  pns,  they  are  found  outside  the  pus 
cells,  rarely  within  these  bodies.  It  stains  readily  with  the  basic  anilin  dyes  and 
is  not  decolorized  by  Gram's  method. 

Staphylococcus  Pyogenes  Albus. — Microscopically,  this  variety  cannot  be 
(lilfcrcutiated  from  the  Stapliylococcns  pyogenes  aureus.  The  difference  be- 
tween the  two  lies  in  the  appearance  of  the  cultures.  The  occurrence  and  sig- 
uilieance  of  the  two  varieties  are  very  similar. 

Bacillus  Proteus  Vulgaris. — The  Bacillns  proteus  frequently  occurs  in  cys- 
titis. It  occurs  as  short  and  long  bacilli,  and  also  in  the  form  of  threads.  It 
is  markedly  motile  and  shows  numerous  flagella.  It  stains  well  wdth  basic 
iiiiilin  dyes  and  is  not  decolorized  by  Gram's  method.  It  forms  grayish-white, 
minute  colonies  upon  agar,  which  later  coalesce  into  a  dirty-gray  translucent 
tihii.  On  gelatin  it  gi'ows  in  the  form  of  grayish-white  colonies  and  liquefies 
the  medium  rapidly. 

The  proteus  is  frequently  found  in  suppurative  conditions  in  the  urinary 
tract,  especially  in  cystitis.  Experimental  cystitis  has  been  produced  by  in- 
jecting cultures  into  the  bladder  in  animals. 

Bacillus  Pyocyaneus. — The  Bacillus  pyocyaneus,  or  bacillus  of  green  pus, 
is  mentioned  here  as  a  germ  occasionally  found  in  cystitis.  It  is  found  in 
fetid  pus  from  wounds.  It  is  a  delicate  rod  with  rounded  or  pointed  ends, 
actively  motile  and  does  not  form  spores.  It  occurs  in  irregular  masses  or 
singly ;  grows  on  all  the  ordinary  media,  giving  a  characteristic  green  color  to 
tlie  same,  which  becomes  blackish  in  old  cultures.  The  bacillus  stains  with 
the  ordinary  anilin  dyes. 

Other  Microorganisms  of  Minor  Importance. — The  rays  or  granules  of 
Actinomyces  may  be  found  in  the  urine  wdien  this  infection  affects  the  genito- 
urinary tract  or  when  this  fungus  is  present  in  the  system  and  finds  its  way 
into  the  urine. 

The  Micrococcus  urece  is  the  germ  which  occurs  in  long  chains  consisting  of 
large  cocci.  It  occurs  in  urines  undergoing  ammoniacal  fermentation  and  de- 
composes urea  into  ammonia. 

Yeast  cells  and  molds  of  various  kinds  are  very  often  found  in  the  urine, 
entering  either  from  the  air  or  as  a  result  of  contamination  from  the  vessels 
in  which  the  urine  is  collected. 

Methods  of  Examining  the  Ukine  for  Bactekia 

Specimens  of  urine  which  are  to  be  examined  bacteriologically  should  be 
obtained  from  the  bladder  by  means  of  a  sterile  catheter  (introduced  after  copi- 
ous washing  of  the  urethra  wntli  boric-acid  solution),  collected  in  a  sterilized 
bottle,  and  handled  thereafter  only  with  sterile  apparatus.     Before  introducing 


116  THE   URINE 

tlie  catheter,  the  external  genitals  in  either  sex  should  be  thoroughly  cleansed 
Avith  soai5  and  hot  water  and  tlie  smegma  removed  from  the  neighborhood  of 
the  orifice  of  the  uretliia.  'Ilie  urine  should  be  examined,  as  a  rule,  as  soon  as 
obtained,  especially  "when  looking  for  tubercle  bacilli,  so  as  to  prevent  decompo- 
sition and  multij^lication  of  extraneous  germs. 

Centrifugation  is  a  rapid  and  most  satisfactory  method  of  obtaining  bac- 
terial sediments.  The  centrifuge  sediment  is  drawn  u\>  liy  a  slender  pipette, 
and  spread  on  slides  and  allowed  to  dry.  The  spread  preparations  are  then 
fixed  by  immersing  in  alcohol  and  ether,  equal  parts,  or  by  passing  slowly 
through  the  Bunsen  flame.  Care  must  be  taken  always  to  spread  the  film  very 
thinly.  The  successful  fixation  of  the  sediment  depends  upon  the  presence  of 
a  certain  amount  of  pus  containing  coagulable  proteid  substances.  AVhen  these 
are  absent  in  the  urinary  sediment,  as  sometimes  is  the  case,  fixation  on  the 
slide  is  not  easily  aceomplislied  without  tlie  addition  of  egg-albumen.  The 
sediment  is  taken  up  with  a  platinum  loop  and  spread  upon  a  slide,  upon  which 
a  drop  of  a  mixture  of  egg-albumen  and  glycerin  has  previously  been  placed, 
and  then  fixed  as  already  described. 

Shreds  from  the  urethra,  clumps  of  fibrin,  masses  of  epithelium  and  other 
tissue  elements  which  may  be  found  in  the  urine,  may  be  examined  for  bacteria 
after  being  fished  out  with  a  platinum  loop  and  spread  on  the  slide  and  stained. 
They  are  fixed  and  stained  in  the  same  manner  as  the  other  smears  from  the 
urinary  sediment,  but  especial  care  should  be  taken  to  spread  them  very  thinly 
by  means  of  a  platinum  needle.  It  is  difficult  to  detect  germs  in  these  shreds 
of  tissue  under  the  best  conditions. 

When  the  bacteria  looked  for  are  absent  from  the  sediment  on  microscopical 
examination  of  stained  preparations,  cultures  and  inoculations  into  animals 
may  be  resorted  to — methods  to  be  employed  when  the  importance  of  the  diag- 
nosis requires  them.  The  details  of  cultivation  and  animal  inoculation  are 
given  under  the  headings  of  the  respective  germs. 


CHAPTER    IV 


DISCHARGES 


Under  tins  heading  wo  shall  consider  the  character  of  all  discharges  fr<jni 
the  genito-nrinary  tracts  of  men  and  women,  whether  they  he  normal  or  ah- 
nornial.  In  the  list  of  discharges  are  included  nrethral,  prostatic  and  seminal 
elements,  which  are  best  considered  under  the  headings  of: 

Urethrorrhea,  Chancroidal  Urethritis, 

Prostatorrhea,  Acute  Gonorrheal  Urethritis,  anterior 

Spermatorrhea,  and  posterior, 

Xonspeciiic  Urethritis,  Chronic  Gonorrheal  Urethritis, 

I'uhercnlar  Urethritis,  Chronic  Prostatitis, 

Syphilitic  Urethritis,  Chronic  Vesiculitis. 

Discharge  for  examination  is  taken  in  the  following  manner : 
Taking-  of  the  Specimen. — In  men,  take  a  slide  between  the  thumb  and  fore- 
tinker  of  the  right  hand  (Uig.  H:^),  and  the  glans  in  the  same  Avay  with  the  left 


Fig.   112. — Manner  of  Holding  the  Slide  in  Taking  a 
Specimen  of  Urethral  Disch.\rge  in  the  Male. 


117 


118 


DISCHARGES 


li.uid,  and  apjily  the  surface  of  the  slide  to  the  meatus  (Fig.  11'3).     The  dis- 
charge on  the  glass  should  then  be  smoothed  out  on  the  slide.     If  none  is  appar- 
ent, draw  the  finger  along  the  urethra 
and   express    its   contents   from    the 
meatus.    If  nothing  appears,  insert  a 
1  *    '  /^^^  /     ^       \  platinum  loop    'Fig.    114)    into  the 

/  /  /  \  fossa    navicular] s    and    even    farther 

"*^  down  the  canal  to  see  if  some  can  be 

obtained.  If  so,  the  secretion  adhering 
to  the  platinum  loop  can  be  smoothed 
out  on  the  surface  of  the  slide  for 
examination.  When  the  discharge  is 
abundant,  a  sufficient  amount  can  be 
taken  on  a  platinum  loop  for  exam- 
ination and  it  is  not  necessary  to 
apply  the  slide  to  the  meatus. 

In  women,  the  patient  should  be 
placed  on  the  table  with  the  feet  in 
the  stirrups.     If  there  is  a  discharge 
about  the  vulva,  a  slide  can  be  pressed 
against  it  and  smear  Xo.   1  can  be 
taken. 
The  vulva  should  then  be  sponged  until  cleansed.     This  exposes  the  open- 
ings of  the  vulvo-vaginal  glands  on  the  inside  of  the  labia  majora,  so  that  the 
contents  can  be  expressed  by  the  finger  placed  upon  the  gland  and  drawn  along 


Fig.  113. —  The  Urethra  Squeezed  Between  the 
Thumb  and  Forefinger  and  Pus  Appearing  at 
the  Meatus. 


a 


Fig.  114.^Platinum  Wire  to  be  Passed  Down  the  Urethra,  to  Take  Some   Discharge   from 

its  Walls. 


its  duct.  If  discharge  appears,  it  should  be  taken  on  a  slide  smear  Xo.  2.  The 
labia  should  then  be  separated  by  the  thumb  and  forefinger  of  one  hand,  when 
discharge  may  be  seen  at  the  meatus.  If  none  is  seen,  the  forefinger  of  the 
other  hand  should  be  inserted  into  the  vagina  as  far  as  the  bladder  and  then 
drawn  along  the  urethra  (Fig.  115),  by  which  means  a  drop  of  moisture  may 


UKETHROKRHEA 


119 


,„ncar  at  the  meatus.  The  smear  is  then  obtained  by  placing  the  slide  against 
'the  month  of  the  nrethra,  or  else  by  taking  it  with  a  platinum  wire  (Smear 
No  3)  A  speciilnm  should  then  be  introduced  into  the  vagma  and  its  wall 
.,„,i  the'  cervix  uteri  examined.  If  discharge  is  seen  at  the  orifice  of  the  cervical 
!,,n,I  it  can  be  taken  by  means  of  a  forceps,  a  swab  or  a  platinum  loop  and 
then  placed  upon  a  slide  (Smear  No.  4).  Figs.  116  and  117  show  slides 
with  smears. 


Fig.  116. — Smears  on  Slides. 
The  slides  are  then   placed   one   on   the   other  with  the 
smear  between  them. 


Fig.  115. — Forcing  the  Discharge 
Out  of  the  Female  Urethra 
BY  Pressure  Against  the  Ca- 
nal WITH  THE  Tip  of  the  Fin- 
ger IN  THE  Vagina. 
The  specimen  can  then  be  taken 

on  a  slide  or  by  platinum  loop. 


Fig.  117. — The  Slides  Together. 
They  are  wrapped  up,  the  name  inscribed,  and  sent  to  the 
laboratory. 


Urethrorrhea  ex  lihidlne  consists  of  a  scant,  mucoid  discharge  which  occurs 
as  an  oozing  in  conditions  of  sexual  excitement.  It  is  in  all  probability  due  to 
an  exaggerated  activity  of  the  muciparous  glands  of  the  urethra  and  ismter- 
estiug  because  its  appearance,  when  noted  by  the  patient,  is  apt  to  frighten 
one  into  the  belief  that  he  has  some  urethral   disease,   or  that  he  is  losing 


semen. 


Under  the  microscope  it  shows  the  presence  of  urethral  epithclia,  mucus, 
a  few  leucocytes  and  a  variety  of  bacteria  normally  present  m  the  urethra. 
It  represents  merely  an  excess  of  the  normal  secretion,  from  which  it  differs  m 
no  way  when  examined  microscopically. 


120 


DISCHAKGES 


Tlie  discharge  is  to  bo  distinguislied  from  prostatorrhea  and  from  sper- 
matorrhea by  the  absence  of  the  Bottcher's  crystals,  in  the  first  instance,  and  of 
spermatozoa  in  the  second.  It  is  differentiated  fnuii  tlio  discharge  of  chronic 
urethritis  by  containing  fewer  epithelia,  and  the  absence  of  pus  cells  and  of 
pathogenic  germs. 

Prostatorrhea. — Prostatorrhea  consists  in  a  leakage  of  prostatic  fluid  from 
the  ducts  of  the  prostate.  It  is  characterized  by  a  discharge  of  a  white,  viscid 
substance  from  the  meatus  during  defecation,  after  urination,  at  times  of  sexual 
excitement  and  sometimes  on  arising  after  a  morning  erection.  The  fluid  is 
free  from  mucin,  but  rich  in  proteid  substances. 

Microscopic  examination  shows  cylindrical  epithelia,  leucocytes,-  lecithin 
globules,  amyloid  bodies  and  ^'  Bottcher's  "  sperm  crystals.  A  few  spermatozoa 
also  may  be  found.     Bottcher's  crystals  are  rendered  more  distinct  if  a  drop 

of  one-per-cent  solution  of 
ammonium-  phosphate  is  added 
to  the  discharge  (Fig.  118). 
They  are  rhombic  prisms  end- 
ing in  fine  points  or  rhondjic 
margins.  If  one  of  these 
prisms  lies  upon  the  other  a 
cross  is  formed  and  if  several 
are  placed  across  each  other  a 
rosette  is  produced. 

Spermatorrhea. — Sper- 
matorrhea is  an  atonic  condi- 
tion, due  to  passive  congestion 
and  leakage  from  the  urethra 
and  all  contributing  genital 
channels.  It  is  characterized 
by  oozing  out  of  the  semen, 
with  or  without  erection  or 
pleasural)le  sensation,  due  to 
erotic  thoughts,  or  light  me- 
chanical stimuli.  It  may,  however,  occur  after  urination  and  defecation,  as  in 
prostatorrhea.  It  is  thick  and  viscid  and  under  the  microscope  shows  large 
numbers  of  spermatozoa,  by  which  it  is  differentiated  from  prostatorrhea. 
Amyloid  bodies  may  or  may  not  be  present.  Besides  spermatozoa,  the  discharge 
contains  testicular  cells,  cylindrical  epithelial  cells  from  the  seminal  vesicles 
and  the  prostate,  flattened  epithelial  cells  from  the  urethra,  large  round  cells 
from  CVjwper's  glands  and  pigment  gTanules. 

Nonspecific  Urethritis.- — ISTonspecific  urethritis  is  an  inflammation  of  the 
urethra  caused  by  infection  with  other  germs  than  the  gonococcus,  or  by  reu- 


FiG.  118.- 


-Spermatic  or  Bottcher's  Crystals. 
(From  Casper.) 


SYPHILITIC   UEETI-miTIS  121 

(loring  active  the  saprophytic  germs  that  may  be  present  in  a  normal  urethra 
ill  a  quiescent  state.  Any  irritant  may  render  the  quiescent  germs  active.  If 
an  irritant  is  injected  into  the  urethra,  sucli  as  strong  solution  of  silver  nitrate, 
there  develops  within  a  few  hours  a  fairly  abundant  purulent  discharge,  a  non- 
specific urethritis  which  to  the  naked  eye  appears  very  much  like  the  beginning 
discharge  of  true  gonorrhea.  It  varies  in  amount  and  from  white  to  yellow  in 
color.  On  microscopical  examination,  this  discharge  presents  a  large  number 
of  fairly  normal  epithelia  from  the  superficial  layers  of  the  urethra,  including 
the  cuboidal  and  the  columnar  varieties,  as  well  as  the  flat  cells  from  the  fossa 
navicularis.  The  epithelia  are  mixed  with  a  more  or  less  abundant  amount 
of  pus,  and  among  and  within  the  pus  cells  may  be  noted  numerous  microor- 
ganisms belonging  to  the  normal  urethral  flora  ;  also  Staphylococcus  albus,  colon 
bacillus  or  strc})tococcus. 

Tubercular  Urethritis. — Tubercular  urethritis  is  nearh^  always  situated  in 
the  prostatic  urethra  and  secondary  to  tuberculosis  of  the  prostate.  The  dis- 
charge is  scanty,  mucoid,  muco-purulent  or  purulent  in  character,  the  amount 
of  pus  depending  upon  the  jiresence  or  absence  of  mixed  infection.  The  micro- 
scope shows  the  presence  of  such  bacteria  as  are  found  in  nonspecific  urethritis, 
niiicns,  urethral  epithelia,  pus,  tubercle  bacilli,  other  microorganisms  of  sec- 
ondary infection  and  connective-tissue  shreds.  When  the  prostatic  urethra  is 
involved  in  cases  of  tuberculosis  of  the  prostate,  prostatic  tissue  may  also  be 
found.  The  specimen  is  placed  on  a  slide  in  the  way  already  outlined 
and  it  is  stained  and  examined  in  the  manner  already  described  in  the  chapter 
on  The  Urine. 

Syphilitic  Urethritis. — Syphilis  may  involve  the  urethra  in  two  ways: 
First,  as  the  initial  lesion  or  hard  chancre  just  within  the  meatus,  and,  second, 
as  an  ulcerating  gumma  of  the  glans  in  the  later  stages  which  extends  into 
the  urethra. 

When  the  initial  lesion  is  in  the  form  of  an  erosion,  the  discharge  is  usually 
scanty  in  amount  and  ranges  from  a  thin  mucoid  to  a  sero-sanguinolent  or  puro- 
sanguinolent  consistency.  It  is  sometimes  quite  profuse  when  due  to  an  ulcer- 
ating chancre.  Microscopical  examination  shows  few  red  blood  cells,  pus  cells, 
mucus,  urethral  epithelium  and  many  bacteria.  The  active  organism  of  syph- 
ilis is  the  Spirocheta  pallida. 

The  Spirocheta  pallida  (Schaudinn)  (Fig.  119),  or  more  correctly,  Tre- 
})onema  pallidum,  is  a  slender  spiral-shaped,  very  motile  organism  with  pointed 
ends,  4  to  1-1  micromillimeters  in  length,  |-  micromillimeter  in  width.  The 
number  of  its  corkscrew-like  spirals  is  extremely  variable,  and  typical  forms 
have  been  noted  with  as  few  as  two  to  four,  or  as  many  as  twenty  and  more, 
twists.  In  the  other  treponema  of  this  group,  for  example,  the  Spirocheta  re- 
fringens,  the  individual  twists  are  fewer,  larger  and  more  wavelike.  The  Spiro- 
cheta pallida  is  present  in  practically  all  acquired  syphilitic  lesions,  including 


122 


DISCHARGES 


Fig.   119. — Spirocheta  Pallida. 


aciiital  aiitl  extra-genital  chancres,  moist  i^apules,  indurated  lympli  glands,  and 

iiiucuiis  patches,  on  the  surface  as  well  as  in  the  interior  of  the  tissues  and  in 

the  blood.  All  the  organs  of 
the  body,  notably  the  supra- 
renal glands,  the  spleen  and 
the  liver,  have  been  found  to 
contain  it  in  congenital  syph- 
ilis. This  microorganism  has 
never  been  encountered  in 
any  disease  except  syphilis. 
Xegative  findings  in  an 
initial  lesion  do  not  prcjve 
that  the  lesion  is  not  a 
chancre,  as  in  typical  initial 
lesions  we  have  failed  to 
find  it  in  repeated  examina- 
tions. 

The  Spirocheta  pallida 
may  be  demonstrated  in  the 
secretions  from  initial  lesions 
of  syphilis  in  two  ways:  (1) 

Direct   examination  of  the  living  organism   by   a   reflecting  condenser   under 

dark  gTound   illumination;    (2)    by   the   staining   methods   of   Goldhorn   and 

Giemsa. 

The  specimen  is  obtained 

as     follows:     The     part    is 

washed  clean  from  discharge 

with    boric-acid    solution. 

The  syphilitic  lesion  is  then 

lightly  curetted  with  a  small 

sterilized  curette  until  blood 

begins  to  ooze;  the  blood  is 

carefully   sponged    off   with 

sterile    gauze    and    usually 

stops  in  a  few  minutes,  after 

which    serum    will    be    seen 

to  ooze  from  the  lesion.     A 

sterile  glass  slide  is  lightly 

touched   to   this   serum   and 

the    specimen    is    fixed    and 

dried    like    ordinary    blood 

smears.  Fig.  119a. — Spirochkta  as  >Et.N  BY  Goldhorn  Stain. 


SYPHILITIC    URETHKITIS 


123 


METHODS    OK    STAININO     THE    SI'IKOCII  KTA    J'ALLIDA 

I.   Goldhorns  Method: 

Goldhorn's  S]3irocheta  Stain  is  used. 

1.  Cover   unfixed   preparation   Avitli    dve.      (The    Goldlidrn    Spiroclieta 

Stain.) 

2.  Pour  off  excess  of  dye  in  three  or  four  seconds  and  immediately 

plunge  the  whole  slide  gently  face  downward   into  water  to  pi-e- 
vent  precipitation  of  the  stain. 

3.  Hold  in  water  for  three  to  four  seconds  and  wash. 

4.  Dry.      (Do  not  let  the  slide  lie  flat  while  drying,  but  stand  it  up  or 

shake  in  the  air.) 

5.  The  specimen  is  then  mounted  by  dropping  on  a  drop  of  Canada  bal- 

sam and  placing  a  cover  glass  over  it.     It  is  examined  microscopic- 
ally with  a  tV  oil-immersion  lens. 

II.   Giemsas  Method: 

1.  Clean  a  test-tnbe  by  boiling  in  soda  solution,  after  which  wash  thor- 

onghly  and  dry. 

2.  Put  thirteen  drops  of  Giemsa's  Solution  II  in  the  test-tube  and  add 

10  c.c.  of  a  0.5-per-cent  solution  of  chemically  pure  glycerin  in 
distilled  water. 

3.  Warm  this  solution  in  flame. 

4.  Cover  fixed  preparation  with  stain,  and  after  five  minutes  pour  off 

and  cover  again  with  fresh  solution ;  after  five  minutes  wash,  dry 
and  mount,  and  examine  with  V3-  oil-innnersion  lens. 


The  reflecting  condenser  under  dark-ground  illumination  offers  a  rajiid 
and  accurate  method  for  the  observation  of  the  living  spirocheta.  This  ap- 
paratus (Fig.  120)  can  be 
attached  to  the  stage  of 
any  microscope  and  held 
in  position  by  the  ordinary 
clips. 

The  condenser  is  pro- 
vitled  with  two  reflecting 
surfaces,  as  shown  iii  Fig. 
121  on  next  page.  The 
jiarallel  rays  of  light  com- 
ing  from    below    (that    is, 

from  the   plane  mirror  of  the  microscope),   are   almost  completely   united   in 
one  point  "  P."     An  intense  ilhnnination  of  the  spirocheta  and  other  organ- 


Fig.   120.— Reflecting  Conde.n^eu. 


124 


DISCHARGES 


isms  is  thus  obtained.  The  light  diffused  by  the  bacteria,  as  represented  by 
dotted  lines,  enters  the  objective  and  thus  produces  an  image  of  the  bacteria. 
The  best  source  of  light  for  dark-ground  illumination  is  furnished  by  a  small 
arc  light  (Fig.  122).  But  whore  this  is  not  available,  a  Xernst  lamp  or  an  in- 
candescent gas  lamp  may  be  used,  in  which  case,  it  is  necessary  to  employ  a 
bull's-eye  lens  on  a  stand,  so  placed  that  it  is  betAveen  the  source  of  light  and 
the  reflecting  mirror  of  the  microscope ;  the  distance  between  the  light  and  the 
lens  should  be  17  em.  and  between  the  lens  and  mirror  reflector  of  the  micro- 
scope 40  cm. 


Fig.  121. — Reflecting  Condenser. 
Q,  glass  slide  with  cover  glass. 
a,  b,  reflected  raj's  meeting  at  P. 
C,  condenser  apparatus. 
O,  objective. 
P,  point  of  concentration  of  the  rays. 


Fig.  122. — Electrical  Arc  Lamp  with  Hand  Feed 
FOR  A  Current  of  4  Amperes  and  an  Illumi- 
nating Lens  Mounted  on  a  Stand. 


The  specimen  to  be  examined  is  taken  on  a  slide,  but  the  serum  is  not  al- 
lowed to  dry;  a  drop  of  distilled  water  is  added  to  it  and  a  cover  glass  placed 
over  it,  and  the  specimen  is  examined  in  the  wet  state.  The  slide  is  now  placed 
on  the  condenser  and,  the  source  of  light  having  been  adjusted,  it  is  then  ex- 
amined either  with  a  dry  or  an  oil-immersion  lens.  The  object  slide  and  cover 
glass  must  be  thoroughly  clean,  as  dust  particles  interfere  with  the  observation ; 
the  preparation  itself  should  be  very  thin  and  the  specimens  must  not  contain 
any  air  bubbles. 

Chancroidal  Urethritis. — This  is  the  result  of  infection  of  the  meatus  by 
chancroidal  virus  and  an  extension  of  a  few  millimeters  do^m  the  canal.  The 
discharge  is  moderately  profuse  in  amount  and  muco-purulent  or  muco-san- 
guinolent  or  puro-sanguinolent  in  character.  Microscopically,  mucus,  epi- 
thelium, pus  cells,  pus-producing  organisms.  Bacillus  of  Ducrey  and  sometimes 
blood  are  found.     The  infective  agent  in  chancroid  is  the  Bacillus  of  Ducrey. 

The  Bacillus  of  Ducrey  is  a  short,  thick  bacillus  with  rounded  ends,  some- 
what like  a  dumb-bell.  It  is  about  1-J  micromillimeters  in  length.  It  is  found 
both  within  the  cells  and  between  them. 


CHEONIC    GONOCOCCAL   URETHRITIS  125 

The  specimen  is  taken  on  a  slide  and  prepared  in  the  usual  way,  and  then 
stained  for  one  half  hour  in  the  following  solution : 

Sol.  acid  horic  five  per  cent oSS ; 

Sat.  sol.  methvlene-hlue  acpieous    .Iv ; 

1  )istillc(l    water .Ivj. 

Tt  is  sometimes  very  difficult  to  demonstrate  the  Ijacillus  in  stained  speci- 
mens, owing  to  the  extremely  small  number  compared  to  the  enormous  numbers 
of  other  bacteria  present. 

Acute  Gonococcal  or  Specific  Urethritis. — This  condition  is  the  most  fre- 
(pu'ut  cause  of  urethral  discharge.  The  constituents  of  the  discharge  are  mucus, 
epithelial  cells,  pns  cells  and  diplococci,  which  are  the  infective  agents  called 
gonococci.  Other  germs  existing  normally  in  the  urethra  or  complicating  the 
original  infection  may  be  present. 

At  the  onset  of  the  disease,  the  discharge  is  mucoid  or  muco-purulent,  ap- 
])caring  as  a  slight  moisture  or  a  drop  at  the  meatus  when  the  gonococcal  in- 
vasion has  as  yet  not  penetrated  farther  than  the  fossa  navicularis.  If  very 
acute  or  moderately  acute,  the  discharge  becomes  more  abundant,  i:)urulent  or 
muco-sanguinolent,  and  the  gonococcus  is  found  in  the  discharge.  The  char- 
acteristic discharge  of  acute  urethritis  contains  but  very  few  epithelia  as  com- 
pared to  the  enormous  number  of  pus  cells  present.  As  the  acute  infection 
licgins  to  subside  and  as  a  proliferation  of  epithelia  goes  on  in  the  process  of 
healing,  the  number  of  epithelial  cells  in  the  discharge  gTOws  larger,  while  the 
relative  number  of  pus  cells  is  less.  Thus  we  are  able  to  gauge  with  fair  ac- 
curacy by  the  microscopical  examinations,  the  acuteness  of  the  urethritis,  by 
the  number  of  epithelia  as  compared  with  the  number  of  pus  cells.  An  excep- 
tion must  be  noted,  however,  during  the  first  few  hours  of  an  acute  attack 
when  the  discharge  is  mucoid  and  when  there  are  more  epithelia  than  pus  cells, 
the  e]utlielia  coming  largely  from  the  anterior  region  of  the  canal,  that  is,  of 
tlie  large,  flat  tj'pe,  irregular  or  polygonal  in  shape.  Gonococci  are  present  until 
the  discharge  has  ceased  or  is  a  simple  moisture. 

Chronic  Gonococcal  Urethritis. — The  discharge  of  chronic  urethritis  differs 
from  tliat  of  the  acute  conditions  in  that  it  is  scanty,  mucoid  or  muco-purulent, 
sometimes  absent  during  the  day,  but  present  in  the  morning.  It  contains  mu- 
cus, uretliral  epithelia,  especially  many  squamous  cells  and  usiuilly  but  a  small 
auiount  of  pus.     Gonococci  are  usually,  but  not  always,  found. 

Gonococci  are  coffee-bean-shaped  micrococci,  grouped  in  pairs,  the  flattened 
surfaces  facing  each  other.  For  this  reason  the  gonococcus  is  generally  spoken 
of  as  di])lococcus.  It  is  usually  found  in  the  pus  cells,  that  is.  intra-eellular, 
occupying  the  ju'otoplasm,  but  never  penetrating  the  nuclei.  It  stains  deeply 
with  anilin  dyes  and  can  readily  be  distinguished  upon  the  paler  background 


126  DTSCIIAKGES 

of  the  pus  cells  or  epitlielia.  Examined  under  high  magnifications,  the  longi- 
tudinal slit  between  the  two  cocci  constituting  the  pair,  can  be  very  distinctly 
nuide  out. 

The  gonococcus  varies  somewhat  in  size,  the  average  being  1.25  microns  in 
length  and  from  O.G  to  0.8  microns  in  diameter.  The  well-developed  and  full- 
sized  germ  is  found  in  acute  conditions,  while  in  some  chronic  cases,  the 
smaller  form  may  sometimes  be  seen,  showing  possibly  an  attenuated  state.  A 
variety  of  sizes  may  be  noted  in  some  pure  cultures. 

The  pairs  of  cocci  are  grouped  usually  in  small  masses;  occasionally,  how- 
ever, a  cell  will  contain  but  a  few  pairs.  In  acute  urethritis,  on  the  other  hand, 
when  the  process  is  virulent,  numerous  pus  cells  will  be  found  so  closely  packed 
with  gonococci,  that  the  cell  protoplasm  is  entirely  masked.  Often,  also,  the 
gonococci  are  found  grouped  about  the  nuclei  of  a  cell,  but  the  cell  body  seems 
to  be  absent,  because  it  is  either  very  faintly  stained  or  has  been  obliterated 
in  the  course  of  the  inflammatory  process.  When  epithelial  cells  occur  in  the 
urethral  discharge,  the  gonococci  are  often  grouped  about  them  or  seem  to  lie 
upon  the  cells  or  within  them.  The  intra-cellular  position  of  the  gonococcus  in 
the  pus  cells,  however,  is  so  characteristic,  that  its  recog-nition  is  made  a  condi- 
tion for  the  morphological  diagiiosis  of  this  germ. 

The  important  part  of  the  examination  of  the  discharge  in  gonococcal  in- 
fection is  naturally  for  the  gonococcus.  The  number  of  gonococci  found  in  a 
specimen  of  gonorrheal  pus  varies  gTeatly,  according  to  the  stage  of  the  disease 
and  the  virulence  of  the  infection.  There  is  also  a  variation  in  the  number  of 
gonococci  found  within  the  pus  cells  in  different  stages  of  the  inflammation. 
They  are  most  numerous  in  the  creamy  discharge. 

A  large  number  of  other  cocci  and  bacilli  are  also  found  in  some  cases  of 
gonorrheal  urethritis  (secondary  infection).  It  is  said  that  when  these  are 
present,  complications  are  more  apt  to  occur. 

In  chronic  cases  accompanied  by  very  little  mucoid  discharge  and  by  some 
shreds  in  the  urine,  it  is  difficult  and  sometimes  impossible  to  detect  gonococci 
either  in  the  discharge  emitted  in  the  morning  (morning  drop),  in  the  shreds 
or  in  the  urine. 

In  cases  of  relapse  or  of  exacerbations  of  a  chronic  gonorrhea,  the  gonococci 
reappear,  although  occasionally  they  are  not  found. 

Methods  of  Staixixg  ajs^d  Examixatiox. — The  first  step  in  this  exam- 
ination is  the  fixation  of  the  smear  upon  the  slide  by  means  of  heat.  This  is 
done  by  taking  the  slide  between  the  thumb  and  forefinger  and  passing  it  slowly, 
smear  side  up,  three  times  through  the  flames  of  an  alcohol  lamp.  The  next 
step  is  to  stain  the  smear  with  one  of  the  anilin  dyes,  which  suffices  in  routine 
work.  In  case  of  doubt  as  to  the  identity  of  the  germ,  it  can  be  determined  by 
Gram's  stain.  It  is  advisable,  in  important  cases,  to  take  several  smears,  so 
as  to  have  material  for  confirmatory  examinations. 


CHRONIC   PROSTATITIS  127 

The  gonococciis  stains  readily  with  the  basic  anilin  dyes,  but  loses  its  color 
when  treated  with  Gram's  method — in  other  words,  it  is  Gram-negative. 

1.  Methylene  Bine.- — A  great  variety  of  staining  methods  have  been  nsed 
for  staining  the  gonococcns.  The  simplest  method,  which  at  the  same  time  is 
perfectly  satisfactory  for  ordinary  clinical  work,  is  with  a  dilute  solution  of 
methylene  bine,  which  is  dropped  npon  the  smear  by  a  medicine  dropper  in 
sufficient  quantity  to  cover  the  slide  and  allowed  to  remain  for  five  minutes ; 
it  is  then  washed  thoroughly  with  distilled  water.  Such  is  the  differentiating 
action  of  this  basic  dye,  that  the  nuclei  of  the  cells  are  stained  a  pale  blue,  while 
the  cell  bodies  are  stained  a  still  paler  tint,  forming  a  background  against  which 
the  gonococci  appear  distinctly.  If  the  preparation  has  been  carefully  and 
thinly  spread,  if  the  light  and  the  optical  conditions  are  perfect,  the  morpliology 
of  the  germ  appears  sharply  defined  with  this  method  of  staining.  (The  for- 
mula for  the  methylene-blue  solution  is  a  matter  of  individual  choice.) 

2.  Grams  Differential  Method. — The  most  important  method  of  differen- 
tiating the  gonococcns  from  other  germs  which  resemble  it,  and  which  may 
occur  in  urethral  discharges,  is  the  method  of  Gram,  to  which  reference  has  al- 
ready been  made  above.  This  method  consists  in  treating  the  smears  with  a 
staining  solution  known  as  ^^  anilin  water  gentian  violet." 

The  anilin  water  is  dropped  on  the  fixed  smear  in  the  same  way  as  the 
methylene  blue  and  allowed  to  remain  five  minutes.  It  is  then  transferred  to 
Gram's  solution  (composed  of  1  gram  of  iodin,  2  grams  of  potassium  iodid,  and 
300  c.c.  distilled  water),  in  which  it  remains  for  about  two  minutes.  It  is 
next  rinsed  thoroughly  in  absolute  alcohol  until  no  trace  of  violet  can  be  seen. 
If  tliere  is  still  some  violet  color,  the  iodin  solution  is  again  used,  followed  by 
rinsing  in  alcohol,  and  this  is  repeated  until  no  trace  of  violet  is  visible.  The 
specimen  is  next  washed  in  water,  and  then  counterstained  for  about  two  min- 
utes in  a  solution  of  1  part  of  Bismarck  brown,  10  parts  of  alcohol  and  100 
parts  of  distilled  water.  The  specimens  are  then  dried  and  examined  with  the 
oil-immersion  lens. 

The  characteristic  feature  of  the  gonococcns  in  specimens  thus  stained  is 
that  it  loses  its  color  when  treated  with  the  decolorizing  solution  of  Gram,  and 
takes  the  brown  counter  stain. 

The  other  bacteria  in  the  preparation,  including  other  diplococci,  which 
may  resemble  the  gonococcns,  retain  the  purple  color  of  the  gentian  violet. 
Gram's  method  is,  therefore,  useful  in  the  diagnosis  of  the  gonococcns  in 
smears.  It  should  be  employed  whenever  there  is  any  doubt  as  to  the  identity 
of  a  diplococcus  found  in  urethral  discharges,  especially  in  medico-legal  in- 
vestigation. 

Chronic  Prostatitis. — Chronic  prostatitis  is  an  inflammation  of  the  jiros- 
tate  usually  following  gonorrhea  or  some  other  urethral  infection.  The  dis- 
charge is  generally  seen  in  the  morning,  having  passed  the  cut-off  muscle  dur- 


128 


DISCHARGES 


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130  DISCHAKGES 

ing  morning  erections,  as  in  prostatorrliea.  The  discharge  is  similar  to  that 
of  prostatorrhea,  plus  pus  and  infection.  It  is  scanty  and  viscid,  and  con- 
tains prostatic  and  urethral  epithelia,  leucocytes  (pus),  mucus,  few  or  no 
sjicrmatozoa,  amyloid  Ixxlies  and  Bijttcher's  crystals,  gonococci  or  other 
bacteria. 

Chronic  Vesiculitis. — Chronic  vesiculitis  is  an  inflammation  of  the  seminal 
vesicles,  due  to  gonorrheal  or  other  infection.  The  discharge  is  scanty  and 
viscid,  and  resembles  that  of  spermatorrhea.  It  contains  urethral,  vesicular  and 
frequently  prostatic  epithelia,  pus  corpuscles,  mucous  and  colloid  material,  gono- 
cocci or  other  microorganisms,  usually  many  spermatozoa,  well  developed  and 
in  different  stages  of  disintegration.  The  condition  is  characterized  by  the  dis- 
charge oozing  out  in  nocturnal  erections,  the  same  as  in  prostatitis. 


DISCHARGES  IN  THE  FEMALE 

In  men  the  discharges  come  from  the  meatus,  as  the  urogenital  canal  com- 
mences in  the  prostatic  urethra,  where  the  secretions  of  the  prostate  and  those 
coming  from  the  ejaculatory  ducts  first  meet  the  urinary  flow.  From  here 
to  the  external  meatus,  the  genital  and  urinary  tract  are  in  common.  In  women, 
the  urinary  and  genital  tracts  first  meet  at  the  vulva  and  therefore  the  dis- 
charges from  the  urinary  and  genital  tracts  would  reach  this  jDoint  in  case  they 
are  sufficiently  profuse. 

A  discharge  found  on  the  vulva  may  come  from  the  vulva  itself,  the  urethra, 
Skene's  glands,  the  glands  of  Bartholin,  the  vagina,  the  cervical  or  uterine 
canals  or  the  Fallopian  tubes,  under  the  following  conditions :  jSTonspecific  ure- 
thritis, acute  gonococcal  urethritis,  chronic  gonococcal  urethritis,  gonorrhea  of 
Skene's  glands.  Bartholinitis,  nongonococcal,  gonococcal,  tubercular,  syphilitic 
and  malignant  disease  of  the  vagina,  chancroids,  in  endocervicitis  or  endome- 
tritis due  to  nongonococcal  or  gonococcal  infection  or  to  tumors,  benign  or  ma- 
lignant, tuberculosis  or  salj)ingitis. 

A  smear  should  be  taken  from  the  vulva  by  touching  it  with  a  glass  slide. 
This  smear  may,  therefore,  contain  a  combination  of  discharges  from  various 
points,  consisting  of  mucus,  pus  and  blood  cells,  epithelia  from  the  mucous 
membrane  of  the  vulva,  urethra,  vagina,  glands  of  Bartholin,  uterus  and  the 
Fallopian  tubes ;  also  gonococci  and  various  other  cocci  and  bacilli. 

The  vulva  should  then  be  wiped  with  a  piece  of  moist  gauze  and  the  dis- 
charges from  the  various  other  contributing  jjarts  should  be  taken  in  the  man- 
ner previously  described. 

Urethral  discharges  occur  in  gonococcal  and  nongonococcal  inflammations, 
just  as  in  the  male.  The  appearance  varies  from  a  thin,  scanty,  transparent  or 
turbid  drop  to  a  thick  yellow  or  greenish-yellow  discharge.  In  nonspecific  in- 
flammations, microscopic  examination   shows  mucus,   pus   cells,   urethral   epi- 


DISCHAKGES    IN    THE    FEMALE  131 

thelinm  and  tlie  various  kinds  of  cocci  and  bacilli  normally  present  in  the 
urethra.     Blood  cells  may  also  be  present,  but  no  gonococci. 

The  gonorrheal  discharge  from  the  urethra  differs  only  on  account  of  the 
relatively  greater  number  of  pus  cells,  plus  gonococci,  both  intra-  and  extra- 
('(•Ihilar.  In  chronic  gonococcal  urethritis,  the  discharge  is  often  very  scanty 
or  iibscut,  in  Avliicli  case  a  specimen  should  be  obtained  by  introducing  a  plati- 
num wire  into  the  ui-cthra.  Skene's  glands  should  then  be  pressed  upon  and 
any  discharge  coming  from  them  should  be  taken.  Very  often  in  latent  cases 
these  glands  harbor  gonococci. 

Discharges  due  to  chancre  or  chancroid  are  the  same  as  in  the  male,  and 
liave  to  be  determined  by  the  presence  of  the  Spirocheta  or  the  Bacillus  of 
Dncrey.  Bartholin's  glands  should  next  be  gently  squeezed,  and  the  discharge 
from  their  ducts  examined.  Bartholinitis  is  due  in  nearly  all  cases  to  gonor- 
rheal inflammation,  and  the  microscopic  examination  of  the  discharge  shows 
mucus,  pus  cells,  columnar  epithelium  from  the  gland's  duct  and  gonococci, 
both  intra-  and  extra-cellular. 

The  discharge  coming  from  the  vagina  is  then  examined.  This  may  come 
from  the  vagina  itself  or  from  the  cervix,  uterine  canal  or  the  Fallopian  tubes. 
'J'liis  discharge  is  known  as  leucorrhea,  although  the  gynecologist  in  whose  field 
it  belongs,  seems  to  use  the  name  less  than  formerly.  A  speculum  is  inserted 
into  the  vagina  and  the  sides  of  its  walls  explored.  The  vaginal  discharge  is 
usually  thin  and  creamy,  although  in  chronic  cases,  it  may  be  thick  and  ad- 
herent. The  examination  may  also  show  a  chancre,  chancroid,  tuberculosis, 
cancer  or  an  inflammation  due  to  gonococcal  or  other  infection.  Smears  or 
scrapings  are  taken  and  the  microscoj)ical  examination  is  made  as  already  de- 
scribed in  the  first  part  of  the  chapter. 

The  cervix  is  then  examined  for  lacerations  or  malignancy.  If  there  are 
no  evidences  of  either  of  these  conditions,  but  a  thick  opaque  discharge,  white 
or  yellow  in  character,  is  seen  coming  from  the  cervical  canal,  the  patient  has 
an  endocervicitis  due  to  a  gonococcal  or  other  infection;  wdiereas,  if  it  is  very 
liurulent,  it  probably  comes  from  the  tubes.  In  case  it  is  due  to  a  gonorrheal 
])rocess,  gonococci  are  present.  If  they  are  not  present,  it  is  due  to  some  other 
infection,  and  has  as  a  predisposing  cause  uterine  displacement,  or  subinvolu- 
tion or  new  growth.  Besides  mucus,  pus  and  the  germs  of  infection,  the  dis- 
charge from  the  uterus  occasionally  contains  ciliated  epithelia. 


CHAPTER    V 

THE   BLOOD   IN   RELATION   TO   UROLOGY 

Blood  examinations  are  especially  useful  in  differentiating  septic  or  sup- 
purative conditions  from  other  fevers,  as,  for  example,  typhoid  or  malarial 
fever.  They  also  give  a  clew  as  to  the  degree  of  resistance  to  be  expected  from 
an  anemic  patient  before  operation ;  while  blood  counts,  periodically  made  after 
operations,  show  us  the  progress  of  our  patients  on  the  road  to  recovery.  The 
degree  of  coagulability  of  the  blood,  determined  before  operation,  gives  us  con- 
fidence to  operate  in  certain  cases,  while  it  warns  us  not  to  in  certain  grave 
conditions  of  the  kidneys  or  the  prostate. 

In  this  brief  chapter  I  shall  confine  myself  to  those  clinical  facts  which 
should  be  known  in  order  to  interpret  properly  the  blood  examinations  fur- 
nished by  the  laboratory. 

Blood  comprises  a  fluid,  liquor  sanguinis  or  plasma,  in  which  float  certain 
specialized  cellular  bodies  known  as  corpuscles.  The  plasma  is  a  solution  of 
various  salts  and  of  proteid  materials  (fibrinogen,  serum  albumin,  serum  globu- 
lin), and  is  the  fluid  medium  which  acts  as  a  recipient  and  carrier  of  metabolic, 
eliminative  and  nutritive  substances. 

The  Percentage  of  Hemoglobin. — In  healthy  men,  the  percentage  of  hemo- 
globin is  from  eighty-five  to  ninety-five  per  cent.  In  robust  persons,  it  may, 
however,  reach  above  one  hundred  per  cent.  A  percentage  below  eighty-five  per 
cent  indicates  anemia.  The  determination  of  the  hemoglobin  percentage  is  a 
most  important  feature  in  blood  examinations  in  both  general  and  urological 
surgery.  All  chronic  surgical  conditions  generally  produce  some  secondary 
anemia,  which  grows  more  profound  as  the  case  progresses.  This  is  especially 
so  in  septic  conditions  and  in  malignant  growths.  In  this  secondary  anemia, 
the  decrease  in  the  hemoglobin  percentage  is  the  first  change  noted  in  the  blood, 
except  in  septic  conditions,  and  frequently  the  hemoglobin  is  diniinishcMl  in 
disproportion  to  the  comparativel}^  slow  or  moderate  decrease  in  the  blood 
cells. 

Corpuscles. — The  corpuscular  elements  of  the  blood  are  divided  into  three 
classes:  (1)  The  red  blood  cells,  or  erythrocytes;  (2)  the  white  cells,  or  leuco- 
cytes and  (3)  the  blood  platelets.     Other  minute  particles  of  irregular-shaped 
bodies,  kno^vn  as  blood  dust  or  hemokonia,  will  not  be  considered. 
132 


LEUCOCYTOSIS  I33 

Blood  Count. — The  blood  count  means  determininfi:;  l)y  count  the  nmn- 
ber  of  red  and  white  blood  cells  contained  in  a  cubic  niillinieter  of  blood. 

The  Red  Cells. — 'I'lie  normal  number  of  I'ed  cells  is  5,000,000  to  the  cubic 
millimeter  of  blood  in  men  and  4,500,000  in  women.  They  contain  about 
ninety  per  cent  of  oxyhemoglobin  and  a  small  amount  of  nucleo-proteid.  Their 
function  is  to  carry  oxygen  from  the  lungs  to  the  tissues  in  loose  combination 
witli  hemoglobin. 

Leucocytes. — The  white  cells  or  leucocytes  in  fresh  blood  appear  as  color- 
less, highly  refractive  bodies,  containing  one  or  more  nuclei,  and  sometimes 
granular  matter  in  their  cell  bodies.  They  number  from  5,000  to  10,000  to 
the  cubic  millimeter,  an  average  being  Y,500.  A  differential  blood  count  means 
an  estimation  of  the  percentage  of  the  different  wdiite  cells,  which  is  of  great 
importance  in  urological  diagnosis.  The  four  varieties  of  leucocytes  found 
(Ehrlich)  are: 

(1)  Small  mononuclear  leucocytes — lymphocytes,  twenty-two  to  twenty-five 
per  cent. 

(2)  Large  mononuclear  and  transitional  leucocytes,  two  to  four  per  cent. 

(3)  Polynuclear  (neutrophile)  leucocytes,  seventy  to  seventy-two  per  cent. 

(4)  Eosinophile  (polynuclear  or  bilobed  nuclei)  leucocytes,  two  to  four 
per  cent. 

Blood  plaques  and  blood  dust  need  no  mention  here,  as  they  are  not  of  in- 
terest in  surgical  conditions. 

Leucocytosis. — When  the  number  of  leucocytes  is  markedly  increased,  we 
have  a  leucocytosis.  Simple  leucocytosis  affects  chiefly  the  polynuclear  leuco- 
cytes and  is  sometimes  styled  "  polynuclear  leucocytosis."  When  the  lympho- 
cytes (small  mononuclear)  are  increased,  the  term  "  lymphocytosis  "  is  used. 
When  the  eosinophile  cells  are  increased  we  speak  of  "  eosinophilia,"  and  when 
several  varieties  of  leucocytes  are  increased,  we  have  a  "  mixed  leucocytosis." 
A  physiological  leucocytosis  may  occur  in  pregnancy,  during  digestion,  after 
exercise,  hot  or  cold  baths,  massage  or  electric  treatment. 

.  A  moderate  leucocytosis  means  from  10,000  to  15,000 ;  a  marked  leucocy- 
tosis from  20,000  to  25,000 ;  and  a  very  marked  one  may  reach  85,000  or  even 
90,000. 

Leucocytosis  in  disease  may  be  temporary  in  acute  and  permanent  in  chronic 
conditions. 

Inflammatory  leucocytosis  is  the  infective  type.  The  theory  of  this  is,  that, 
when  infectious  agents  (bacteria,  etc.)  enter  the  system,  they  generate  chemical 
substances  which  have  the  property  of  attracting  leucocytes  into  the  blood  out 
of  their  hiding  places  in  the  spleen,  the  marrow,  etc.  In  addition,  however,  the 
influence  of  germs  seems  to  favor  the  formation  of  new  leucocytes  in  the  mar- 
row, spleen  and  lymphatic  glands,  and  it  is  from  these  sources  that  we  have 
leucocytosis  in  the  blood — emigrated  and  newd}^  formed  leucocytes. 


134  THE   BLOOD   IN   RELATION   TO   UROLOGY 

Leucocytosis  and  Infectious  Diseases. — The  importance  of  leiicocytosis 
in  an  infectious  process  can  be  realized  when  we  consider  that  the  leucocytes 
attack  bacteria  and  eni>-ulf  them  within  their  prf)toplasm,  where  the  germs  are 
digested  by  a  special  ferment  or  killed  by  a  bactericidal  substance  which  exists 
in  the  white  cells.  The  leucocytes  are,  therefore,  the  body's  army  of  defense, 
sent  out  to  annihilate  the  enemy,  which  is  the  germ,  and  this  process  is  called 
'phagocytosis.  Blood  serum  and  lymph  also  contain  bactericidal  substances 
which  take  part  in  the  fight  against  the  germs  and  their  poisons. 

A  person  wdth  strong  resistance  to  infection  will  develop  a  marked  leucocy- 
tosis when  a  virulent  germ  enters  the  system.  A  person  with  poor  resistance, 
on  the  other  hand,  will  have  a  slight  or  no  leucocytosis  when  the  same  germ 
enters.  In  a  person  with  good  resistance,  even  a  mild  infection  will  produce 
moderate  leucocytosis.  We  see  at  once  how  leucocytosis  may  be  employed 
to  gauge  the  constitution  of  the  patient  in  a  septic  case  before  a  serious 
operation. 

The  importance  of  blood  examination  is  shown  in  the  following  diseases, 
occurring  in  or  with  diseases  of  the  urinary  tract : 

Septicemia,  Malaria,  ]  >-r    , 

rr.    1  1       .  c^        ^  '^^        C  ^^  IcUCOCytOSlS, 

luberculosis,  feyphilis,  ) 

Gonorrheal  Infection,  Hemorrhage, 

Peritonitis,  Malignant  Growths. 

(a)  Septicemia. — In  septicemia,  patients  with  a  slight  resistance  to  infec- 
tion have  no  leucocytosis.  The  prognosis  of  those  cases  is,  as  a  rule,  unfavor- 
able. In  most  patients,  however,  there  is  a  distinct  pohjnuclear  leucocytosis. 
The  prevalence  of  polynuclear  cells  in  septicemia,  in  fact  in  any  septic  condi- 
tion, serves  to  differentiate  these  affections  from  typhoid  fever,  Avhere  the  whole 
number  of  polynuclear  leucocytes  is  diminished,  but  the  lymphocytes  are  mark- 
edly increased.  When  typhoid  is  complicated  by  suppurative  conditions,  this 
rule  does  not  hold  good  and  a  leucocytosis  is  present.  In  such  cases,  one 
must  rely  upon  the  Widal  test. 

(&)  Tuberculosis. — In  tuberculosis,  no  inflammatory  leucocytosis  results 
unless  a  mixed  infection  is  present,  Avhen  a  polynuclear  leucocytosis  occurs. 

(c)  Gonorrheal  Infection. — In  gonorrheal  infection,  a  moderate  leucocy- 
tosis of  the  polynuclear  type  is  found,  especially  in  acute  gonorrhea  when  ac- 
companied by  fever  and  complicated  by  epididymitis,  orchitis,  etc.  The  gouo- 
coccus  can  be  isolated  from  the  blood  in  gonorrheal  endocarditis  and  other 
gonorrheal  metastases. 

(d)  Peritonitis. — All  forms  of  peritonitis,  except  the  tuberculous,  produce 
a  leucocytosis,  unless  the  patient  is  very  weak.  A  sudden  rise  in  the  number 
of  leucocytes  indicates  a  spread  of  the  process.  Chronic  cases  are  associated 
with  increasing  anemia. 


BACTERIA   IN   THE   BLOOD  I35 

(e)  Cachectic  Leucocytosis. — In  malignant  tnmors  there  is  leucocytosis 
which  becomes  more  marked  as  the  disease  advances,  and  which  is  due  to  the 
local  inflammation  (that  is,  nlceration  and  necrosis)  and  the  chronic  toxemia. 
The  blood  is  nsnally  normal  in  the  early  stages.  A  profound  anemia  with  a  dis- 
tinct leucocytosis  follows  later,  due  to  toxemia.  Usually  the  ratio  of  the  poly- 
nuclear  cells  is  increased,  but  occasionally  there  is  an  increase  in  the  mononu- 
clears, or  myelocytes  may  be  present.  The  anemia  becomes  profound  as  the 
cachexia  advances.  In  some  cases  of  sarcoma,  there  is  a  marked  lymphocytosis, 
the  blood  looking  like  that  of  lymphatic  leukemia. 

(/)  PostJieniorrhagic  Leucocytosis. — Great  loss  of  blood  is  followed  by  a 
nuirked  increase  in  the  white  cells.  This  leucocytosis  rapidly  disappears  before 
tlie  red  cells  reach  their  normal  level  and  is  due  to  the  pouring  in  of  the  lymph 
to  take  the  jilace  of  the  lost  blood. 

The  Degree  of  Coagulability. — The  degree  of  coagulability  of  the  blood  is 
of  great  interest  to  the  surgeon.  In  urology,  it  is  of  special  importance  in  cases 
of  tumor  of  the  bladder  and  kidney,  and  also  when  such  operations  as  prosta- 
tectomy and  nephrectomy  are  contemplated,  where  much  bleeding  and  oozing 
may  be  expected.  Koughly  stated,  the  blood  normally  clots  within  five  minutes. 
If  the  clotting  is  delayed  to  ten  or  fifteen  minutes,  one  may  look  for  a  danger- 
ous oozing  or  hemorrhage  in  the  patient.  A  number  of  conditions,  chief  among 
them  hemophilia,  purpura  and  jaundice  (cholemia),  produce  a  deficient  coagu- 
lal)ility.  Wright's  coagulometer  is  an  instrument  used  to  measure  this  physical 
property  of  the  blood.  If  the  coagulability  is  found  deficient,  the  usual  treat- 
ment with  calcium  chlorid,  gelatin,  etc.,  may  be  employed. 

Bacteria  in  the  Blood. — The  discovery  of  specific  bacteria  in  the  blood  is 
not  an  easy  matter,  and  requires  the  most  rigid  aseptic  technique  and  the  utmost 
Avatchfulness  and  skill  in  the  preparation  and  use  of  the  various  media.  But 
few  germs  occur  in  the  blood  in  such  numbers  that  they  can  be  detected  in 
ordinary  smears.  The  principal  microorganisms  which  are  found  in  the 
blood  are : 

(1)  Streptococcus  and  Stapliylococcus. — In  septic  conditions,  malignant  en- 
docarditis, etc.,  their  presence  in  the  blood  always  means  a  bad  prognosis,  but 
care  must  be  taken  to  exclude  accidental  contamination  by  the  Staphylococcus 
a] bus  always  present  in  the  skin. 

(2)  Tubercle  Bacilli. — This  has  been  found  in  the  blood  in  acute  miliary 
tuberculosis  and  is  difficult  to  detect,  but  it  exists  probably  oftener  than  is 
supposed. 

(3)  Gonococcus. — The  gonococcus  has  been  isolated  from  the  blood  in  a 
number  of  cases,  principally  in  maligiiant  endocarditis  due  to  gonorrheal  in- 
fection. 

(4)  Bacillus  Coli. — The  bacillus  coli  can  be  often  detected  in  the  blood  in 
some  form  of  septicemia  in  urological  cases. 


136  THE    BLOOD    IN   RELATION    TO   UROLOGY 

(5)  Typhoid  Bacillus. — Typhoid  bacillus  is  always  present  in  the  blood  in 
typhoid  fever  and  is  not  difficult  to  detect. 

An  important  point  to  remember  is  that  the  absence  of  a  germ  from  the 
blood  is  not  to  be  regarded  as  a  negative  diagnostic  factor. 

(6)  Protozoa  in  tlie  Blood. — Among  these  are  the  Plasmodia  malaria^  and 
the  embryos  of  Filaria  sanguinis  and  the  spirilla  of  European  and  African  re- 
current fever. 


.  CHAPTER    VI 
UROLOGICAL  EQUIPMENT 

Iisr  considering  nrological  equipment,  we  will  discuss  the  space  that  the 
physician  uses  for  his  office  work,  his  office  furniture,  apparatus,  instruments 
and  dressings.  In  case  he  has  a  clinic  or  hospital  service,  it  should  also  be 
taken  into  consideration.  The  methods  of  conducting  his  private  and  institu- 
tional work  should  also  be  spoken  of. 

Space  Required  for  Office  Work. — In  order  to  do  good  work  in  urology,  it 
is  not  necessary  to  have  an  elaborate  plant;  efficient  urological  work  can  be  done 
and  is  done  in  a  very  limited  space. 

This  usually  consists  of  one  room  in  which  the  patients  wait,  called  a  re- 
ception room,  and  another  in  which  to  attend  them,  called  the  office,  situated 


TJ 


OO 


o 


V 


0     Q 


D 


o 


a 


n 


Fig.   123. 


D 


n 


D 


on  the  same  floor.  The  office  proper,  in  case  it  consists  of  but  one  room,  is  a 
combined  consultation  and  treatment  room.  Such  was  my  office  for  many  years. 
(See  Fig.  123.) 

137 


138 


UROLOGICAL   EQUIPMENT 


Here  it  will  be  seen  tliat  the  waiting  room  faced  the  patient  on  entering, 
while  the  office  opened  into  the  hall  on  the  left.  The  office  was  a  large  one,  hav- 
ing two  windows  facing  the  street,  on  the  opposite  side  to  which  were  two 
doors,  one  opening  into  the  hall,  the  other  into  the  waiting  room.  Tlie  two  re- 
maining sides  of  the  room  with  their  corners  were  used  for  my  library  and 
ecpiipment. 

On  the  side  of  the  room  extending  from  the  hall  door  to  the  front,  was  an 
open  bookcase  with  hanging  curtains  on  the  shelves.  In  the  corner  of  this, 
near  the  adjacent  window,  was  placed  my  microscope  with  its  accessories. 

On  the  opposite  side  of  the  room,  was  the  fireplace  in  the  center  and  a  cabi- 
net with  shelves,  resembling  a  bookcase,  extending  from  it  to  the  wall  on  either 
side.  The  space  between  the  fireplace  and  the  window  contained  everything 
required  in  the  office  for  urological  work — the  examining  table,  the  instrument 
table  and  an  open  cabinet  on  the  shelves  of  which  were  all  the  apparatus,  instru- 
ments and  dressings  used  for  the  examination  and  treatment  of  patients.  In 
a  corner  corresponding  to  the  space  between  the  fireplace  and  the  reception- 
room  door,  was  kept  my  sterilizing  and  throat  apparatus.  The  fourth  corner 
was  unavailable  on  account  of  the  presence  of  the  hall  door. 

In  my  one-room  office,  everything  that  was  used  for  my  microscopical 
and  throat  examinations  was  kept  on  the  shelves  of  the  bookcase  or  cabinet 
and  just  before  office  hours  was  placed  on  the  tables  in  the  corners,  ready  for 
use ;  and  they  were  put  away  again  after  office  hours.  The  corner  where  the 
examining  and  instrument  tables  and  the  urological  apparatus  and  instruments 


n rr 


/ 

0 

Fig.   124. 


were  kept,  was  hidden  by  a  screen.  Within  a  few  minutes,  this  room  was  trans- 
formed from  a  library  into  an  office  and  vice  versa  twice  a  day.  Everything 
pertaining  to  my  work  was  kept  in  this  one  room  and  there  was  no  running 
about,  no  looking  for  things  that  were  in  some  other  room.     The  only  disad- 


APPARATUS    AND    INSTRUMENTS   FOR   OFFICE 


139 


A'niitnii'c  of  this  liniited  spaeo  was  that  T  conld  only  do  a  certain  niiionnt  of  work 
in  the  time  allotted  to  otHee  hours. 

In  the  course  of  time  it  became  necessary  to  add  more  space.  The  first  step 
AViis  to  convert  the  adjoining  reception  room  into  a  treatment  room  and  to  place 
ill  it  a  similar  equipment  to  that  which  I  already  had  in  my  single  office  be- 
hind the  screen.  I  took  an  adjoining  room  for  my  patients  to  wait  in,  thus 
mnkiug  a  consultation,  treatment  and  reception  room.  (See  Fig.  124.)  This 
enabled  me  to  have  a  patient  in  the  consultation  room  and  another  in  the  treat- 
ment room  at  the  same  time.  It  also  permitted  me  to  have  an  assistant  to 
handle  the  old  cases  while  I  was  examining  the  new  ones. 

As  my  practice  increased,  I  added  another  room  as  a  laboratory,  thus  mak- 
ing a  complete  suite  of  offices.     (See  Fig.  125.) 


Fig.  125. 


Office  Furniture.— The  consultation  room  in  a  urological  office  can  be  fur- 
nished in  any  way  that  the  practitioner  desires,  but  it  is  desirable  to  have 
strong,  heavy  furniture,  preferably  of  a  dark  color,  covered  with  leather.  It 
should  consist  of  a  table-desk,  a  number  of  chairs  and  a  couch ;  also  a  book- 
case, if  it  contains  the  library.  Besides  this,  if  the  patients  are  to  be  treated 
in  the  same  room,  it  should  have  additional  office  furniture  indicated  for  a 
one-room  office,  such  as  an  examining  table  for  the  examination  and  treatment 
of  patients;  an  instrument  table;  a  small  table  for  microscope,  or  for  whatever 
other  purpose  the  practitioner  might  desire ;  a  cabinet  for  apparatus  and  in- 
struments and  a  lamp — electric  or  gas  (probably  both).  Small  stools  and 
tables  are  always  convenient  and  take  up  but  little  space. 

Apparatus  and  Instruments  Recommended  for  Office. — Tables. — For  ex- 
amination and  treatment  of  patients ;  for  instruments ;  for  microscope  and  ac- 
cessories. 

Lamp. — With  a  reflector — electric,  gas  or  oil. 

Sterilizer. — Steam,  formalin,  a  pan  for  boiling  instruments. 

KuBBEK  Goods. — Rubber  tubing  for  irrigating  jars ;  hard-rubber  irrigating 
tips,  shields  and  cut-offs ;  finger  cots. 


140  UKOLOGICAL   EQUIPMENT 

Glassware. — Irrigating  jars;  jars  for  dressings;  jars  for  solutions;  glass 
graduates  ;  urine  tubes ;  medicine  droppers. 

Graniteware. — Basins  for  solutions ;  douche  pan  ;  pus  basin. 

Piston  Syringes. — Large  and  small  urethral;  bladder;  hypodermic. 

Dressings. — Assorted  bandages;  T-bandages;  cotton  balls;  tampons;  sani- 
tary pads ;  gauze  compresses — 3  by  5  ;  5  by  6 ;  8  by  10 ;  gauze  compresses  with 
cotton-combined  dressings — 5  by  6 ;  8  by  10 ;  adhesive  plaster. 

Miscellaneous. — Instrument  tray ;  galvanic  and  f  aradic  battery ;  small 
water  barrel  (for  hot  water)  ;  tub  for  bichlorid  solution  in  which  to  sterilize 
utensils  requiring  chemical  disinfection ;  stirrups  and  lithotomy  uprights  for 
examination  and  treatment  tables. 

Cocain  tablets ;  bichlorid  tablets ;  peroxid ;  Holzien  solution ;  silver  solu- 
tion ;  boric  acid ;  alcohol ;  lubricants  (glycerin,  gommenol)  ;  green  soap ;  brushes. 

Instruments. — Special. — Catheters — soft  rubber^  straight  or  elbowed; 
woven,  straight  with  olivary  tip  and  elbowed;  metal. 

Filiform  bougies ;  bougies  a  boule.  Cystoscope. 

Sounds.  Prostatic  douche  tubes. 

Stone  searcher.  Instillating  syringe. 

Dilators — Kollmann  and  Oberliinder.  Applicators. 

Urethroscope.  Tunneled  sound  and  catheters. 

Perineal  grooved  probe,  director,  cannula  and  gorget;  perineal  drainage  tube. 

Rectal  bag. 

Prostatic  forceps  and  depressor. 

General. — Retractors,  dull  with  rounded  edge,  large  and  small;  sharp  with 
short  teeth. 

Probe,  grooved  director. 

Scissors,  dull  curved,  sharp  curved ;  dull  straight. 

Knives,  straight  scalpels,  large  and  small ;  straight  and  curved  bistouries. 

^Needles,  large  and  small  Hagedorn's,  short  round,  surgical  and  straight, 

^Needle  holder. 

Forceps,  thmnb;  artery,  curved  with  long  slender  blades;  bullet. 

Sponge  forceps. 

Vaginal  speculum,  depressor,  dressing  forceps. 

Throat  mirror  and  tongue  depressor. 

Sutures,  ligature  material,  catgut  jDlain  and  chromic,  ISTos.  1,  2  and  3  ;  braided 
silk. 

Ligature  carrier. 

Kelly  pad. 

Paquelin  cautery. 

Extra  Equipment  for  Outside  Work. — Besides  the  office  equipment,  little 
is  needed  for  outside  visits.  The  following  list  will  show  what  is  generally  used 
for  operations  and  cystoscopy  outside  of  the  office. 


EXTRA   EQUIPMENT   FOR   OUTSIDE    WORK 


141 


For  Cystoficopy 
Rheostat. 

Two  cystoscopes  and  cords. 
Bougies  a  bonle ;  sounds. 
Assorted  catheters. 

r  Bladder. 
Syringes   i    UrethraL 

'-  Fountain. 
Glycerin, 


BAGS    FOR    OUTSIDE    WORK 

Foi'  Operation 
Portable  metal  table. 
Rubber  sheeting  and  Kelly  pad. 
Basins. 

Sterilized  towels. 
Green-soap  tincture. 
Brushes  and  nail  file. 
Alcohol. 
Bichlorid  tablets. 


Test  glass. 
Cocain  solution. 

Syringes 

r  Fountain  and  piston. 
1  Hypodermic. 

Bichlorid  tablets. 

Assorted  catheters,  knives,  scissors. 

Silver  solution. 

Lubricant. 

Medicine  dropper. 

Cocain. 

Rubber  tubing. 

Peroxid. 

Suppositories  of  morphin  and  quinin. 

■  r 

Thumb. 

Kelly  pad. 

Artery. 

Rubber  sheeting. 

Forceps  < 

Sponge. 

Table  and  lithotomy  leg  rest. 

Bullet. 

Sterilized  towels. 

- 

Prostatic. 

Cotton  balls. 

Assorted  retractors. 

Gauze  pads. 

Assorted  needles. 

Battery,  if  no  electric  light. 

l^eedle  holder. 

Sutures     1                     r  Plain. 

and          I  C'-^tgut     1  Chromic. 

Ligatures  J    Braided  Silk. 

Sounds. 

Bougies  a  boule. 

Gouley  tunneled  sound  and  catheter 

Filiforms. 

TT     .                  fOtis. 
Urethrotomes  i  -,r  • 

(^  JNlaisonneuve. 

'  Grooved  probe. 

Perineal 

Grooved  director. 

< 

Grooved  cannula. 
.  Gorget. 

Bandages,  assorted  dressings. 

Lare-e  catheter  drain  tubes. 

Portable  sterilizer. 

Pedicle  clamp. 

Infusion 

jars. 

142  UROLOGICAL   EQUIPMENT 

Office  Dressing-  Equipment. — Towels. — A  large  supply  of  office  towels, 
18  by  36  in  size,  must  be  kept  on  hand.  The  variety  known  as  "  glass  "  towels 
are  the  best  for  general  use.  They  are  kept  wrapped  in  an  outer  towel,  or 
preferably  in  a  piece  of  muslin,  in  packages  of  ton  for  office  work  and  six  for 
outside  operating.     The  packages  of  towels  should  be  kept  in  a  tin  box  as  stock. 

Cotton  Balls. — These  are  convenient  in  office  work  for  sponging  the 
meatus  and  glans  in  men,  and  the  vulva,  meatus  and  vagina  in  women,  before 
instrumentation.  They  are  kept  in  glass  jars  on  a  treatment  table.  Before  us- 
ing, they  should  be  dipped  into  a  bichlorid  solution,  which  should  always  be 
kept  in  a  jar  close  at  hand.     The  solution  should  be  changed  daily. 

Gauze. — This  is  a  most  useful  surgical  dressing,  and  much  care  sliould 
be  given  to  its  j)reparation  and  sterilization.  The  following  varieties  of  gauze 
dressings  are  useful.  They  should  be  kept  in  separate  jars  and  a  supply  should 
be  in  each  room,  while  a  sufficient  supply  should  be  kept  in  tin  boxes  for  office 
and  outside  work. 

Gauze  sponges,  3  by  6  inches,  for  absorbing  blood,  etc.,  during  an  operation 
and  for  use  with  probangs  or  sponge  holders,  are  folded  from  pieces  of  gauze 
9  by  16  inches.  They  are  also  useful  unfolded  to  wrap  about  the  forefinger  in 
making  a  rectal  examination. 

Sponges  or  compresses,  5  by  6  inches,  are  made  of  pieces  of  gauze,  15  by  18 
inches,  folded  three  times  each  way,  with  the  cut  edges  inside.  They  can  be 
stitched  at  their  free  borders  or  left  free  as  the  surgeon  prefers.  They  are 
packed  in  tiers  in  jars,  or  are  tied  up  in  packages  containing  four  pads  each, 
wrapped  and  pinned  in  pieces  of  muslin.  Some  of  these  packages  may  contain 
in  addition  a  number  of  cotton  balls,  as  these  are  better  adajDted  for  use  in  a 
minor  operation. 

Large  gauze  compresses  for  abdominal  pads  are  gauze  pieces,  18  by  21 
inches,  folded  to  make  pads,  6  by  8  inches.  For  abdominal  sponges  these  gauze 
pads  should  have  their  edges  sewed  and  provided  with  tapes. 

Gauze  packing  strips  should  be  an  inch  wide  and  three  yards  long.  A  thread 
is  pulled  from  a  piece  of  gauze  of  this  length  and  the  strip  is  cut  along  the  line 
indicated.  These  strips  are  kept  in  eight-inch  tubes  plugged  with  cotton,  the 
tubes  being  in  turn  kept  in  jars.  When  the  dressing  is  needed,  it  is  pulled  out 
with  sterile  forceps  and  cut  with  sterile  scissors. 

Strips  of  gauze,  an  inch  wide  and  a  yard  long,  saturated  with  five-  or  ten- 
per-cent  iodoform  and  others  of  the  same  size,  saturated  with  Balsam  of  Peru, 
are  also  kept  in  stock  for  packing  wounds. 

Other  Dressings. — Bandages,  both  gauze  and  muslin,  from  1  to  4  inches 
wide,  are  used  for  office  work  and  outside  operating.  They  can  be  wrapped  in 
sets  of  from  two  to  four  in  pieces  of  muslin. 

EuBBER  tissue  in  assorted  sizes  is  scrubbed  with  green  soap  and  is  kept  in 
1 :  500  solution  of  bichlorid. 


OFFICE   DRESSING   EQUIPMENT 


143 


SuRGiCAT.  PLASTER  ((Hacliylon  or  zinc  oxid)  is  kept  in  convenient  rolls. 
For  small  dressings,  pieces  of  diachylon  })laster,  1  inch  wide  by  4  to  6  inches 
long,  arc  kept  in  readiness  in  a  small  jar  and  are  known  as  dressing  holders. 
They  are  heated  for  a  moment  over  an  alcohol  lamp  before  being  applied. 
Ordinary  adhesive  plaster  is  nsed  for  strapping  on  dressings  of  large  size. 

Forceps  for  taking  dressings  and  gauze  ont  of  jars  and  tubes  are  sterilized 
by  dipping  into  pnre  carbolic  and  alcohol,  or  are  kept,  during  office  hours,  in  a 
ghiss  jar  containing  five-per-cent  carbolic. 

Glass  hand  syringes,  irrigator  tips  and  shields,  couplings  of  glass 
OR  HARD  RUBBER  are  kept  on  the  treatment  table  in  alcohol  or  bichlorid  solution. 
Infusion  jars  are  rarely  nsed  in  office  work,  but  they  are  an  important  part  of 
the  outfit  for  an  outside  operation  and  should  be  provided  with  a  thermometer. 

Needles,  threaded  with  silk  or  unthreaded,  are  put  through  pads  of  gauze 
in  assorted  sizes  and  varieties.  The  pads  with  their  needles  are  wrapped  in 
small  pieces  of  muslin  and  sterilized  by  dry  heat  or  formaldehyd.  The  packages 
are  thus  ready  for  operations.  Ordinarily,  needles  of  assorted  sizes  are  kept 
in  covered  glass  dishes  containing  a  mixed  powder  of  boracic  acid  and  lyco- 
podium.     The  suture  material  is  all  kept  in  tubes  ready  for  use. 


A 


/^ 


^ 


/^ 


Ci 


A 


3 


^ 


b 


o 


Fig.  126. — Table  in  the  Examining  Room. 
On  the  top  are  kept  in  jars,  gauze  cotton  balls,  lubricants,  syringes  in  alcohol,  applicators,  catheters, 
urethral  speculum,  sterile  water,  magnifying  glass.     On  the  lower  shelf,  urine  cylinders,  finger  cots, 
vaseline,  material  for  quick  urinary  tests,  two  dishes,  and  cases  for  instruments. 


144 


UROLOGICAL   EQUIPMENT 


HYroDERMic  SYRINGES  are  kept  with  their  needles,  etc.,  in  a  small  glass 
tray.     The  needles  should  always  have  wires  in  them  when  not  in  use. 

Arrangement  of  Author's  Present  Offices. — In  arranging  my  rooms  for 
office  work,  it  was  necessary  for  me  to  convert  the  basement,  situated  imme- 
diately under  my  consultation  room,  into  a  reception  room.  This  was  easily 
done  and  it  was  connected  with  the  offices  and  treatment  rooms  above  by  a 
private  staircase.  The  arrangement  of  the  office  floor  still  remains  as  it  was 
then  planned. 

Room  No.  1  is  the  consultation  room,  containing  bookcases  for  the  larger 
part  of  the  library,  a  table,  a  desk,  a  letter  file,  two  easy  chairs,  two  arm- 
chairs, two  ordinary  chairs  and  a  couch.  It  opens  into  the  examining  room 
CNo.  2)  by  one  door  and  into  the  hall  by  another. 

Boom  No.  2,  the  first  examining  and  treatment  room,  is  painted  and  fur- 
nished entirely  in  white.  It  contains  an  examining  table,  an  instrument  table 
(Fig.  126),  a  tray  table,  two  stools,  a  chair,  a  commode,  a  screen  and  a  cabinet 
for  apparatus  and  instruments. 

The  examining  table  is  of  the  counterbalance  variety,  with  a  drain  pan 
below  (Fig.  127).     The  seat  section  of  this  table,  on  which  the  buttocks  of  the 


Fig.  127. — Author's  Counterbalance  Table  in  the  Position  for  Examination  of 

Male  Patients. 


patient  rest,  is  made  of  two  pieces  of  glass  with  a  slit  between  them,  which 
allows  the  fluids  used  in  treatment  to  drain  into  the  pan.  The  head  or  back 
section  can  be  raised  to  any  position  (Fig.  128)  for  facilitating  the  examina- 
tion of  the  abdomen,  or  increasing  the  comfort  of  the  patient;  while  the  leg 
part  of  the  table,  for  supporting  the  lower  extremities,  can  be  removed  and  the 
hip  portion  elevated  for  cystoscopy.  With  the  leg  section  removed,  this  table 
makes  an  ideal  table  for  treating  women,  as  the  solutions  run  into  the  pan  below. 
Care  must  be  taken,  however,  to  see  that  the  patient,  when  lying  on  the  table, 


ARRANGEMENT    OF   AUTHOR'S   PRESENT   OFFICES 


145 


sits  on  the  middle  part  first,  as  seating  oneself  on  either  of  the  end  pieces  might 
result  in  falling  to  the  floor.  The  patient  must  also  be  instructed  in  moving 
about  on  th(^  table  to  take  hold  of  the  side  bars,  as,  if  the  top  of  tlie  table  is 


Fig.  128. — Different  Positions  in  Which  the  Patient  Can  be  Placed  in  Examining  the  Abdominal 
Organs,  especially  in  Kidney  Cases,  by  Raising  and  Lowering  the  Shoulder  Piece  of  the 
Table. 


grasped  when  the  shoulder  part  is  elevated,  the  fingers  might  be  crushed  in 
case  that  part  of  the  table  were  to  slip  from  the  cog  in  which  it  is  caugkt. 

Over  the  examining  table  is  placed  a  large  tray  table  on  an  adjustable 
stand,  which  is  exceedingly  convenient  for  holding  close  at  hand  the  various 
instruments  used  in  the  examination  of  the  patients  while  on  the  table. 


Fig.   129. — Counterbalance  Table  with  a  Douche-pan  on  It. 

This  counterbalance  table  is  probably  the  best  antiseptic  metal  table  that 
has  ever  been  placed  on  the  market.     The  slit  in  the  seat  part,  however,  does 


146  UROLOGTCAL   EQUIPMENT 

not  prevent  the  solutions  from  wetting  the  patient  during  urethra  and  bladder 
washings,  when  it  is  covered  by  the  leather  pad,  and  the  glass  or  metal  is  too 
cold  for  the  bare  buttocks.  I  have  personally  found  an  ordinary  wood  table 
of  my  own  designing  more  convenient  for  treatment  than  these  more  modern 
ones  and  they  are  more  pleasing  to  the  patient.  I  have  consequently  gone  back 
to  first  principles,  in  that  I  do  not  depend  on  the  slit  in  the  modern  tables  for 
draining  away  solutions  during  medication,  but  prefer  to  place  a  dcniche  pan 
under  the  patient's  buttocks,  finding  that  in  this  way  the  buttocks  and  clothing 
are  kept  dry  (Fig.  129). 

In  the  instrument  closet  are  kept  all  the  instruments  and  supplies  necessary 
for  a  thorough  examination  and  treatment  of  a  patient  in  the  office  and  outside, 
as  well  as  for  an  operation.  On  the  top  of  the  closet  is  a  row  of  glass  jars  for 
dressings.  Behind  the  screen,  near  the  washstand,  the  commode  is  placed,  for 
the  use  of  the  female  patients  when  they  void  urine  for  specimens. 

Room  No.  3  is  the  next  room  and  has  communicating  doors  with  Room  Ko.  2 
as  well  as  with  the  corridor.  In  the  little  passage  between  Rooms  jSTo.  2  and  Xo. 
3,  on  shelves,  are  bottles  containing  sterile  water  and  solutions,  also  irrigators 
and  other  appliances  kept  in  reserve. 

Room  'No.  3,  also  finished  in  white  entirely,  with  an  impermeable  floor, 
contains  a  counterbalance  table  of  the  same  pattern  as  that  in  ISTo.  1.  It  is  also 
surmounted  by  an  instrument  tray  with  a  stand  (adjustable).  One  or  more 
irrigators  are  hoisted  on  pulleys  over  the  table  from  the  ceiling,  in  a  manner 
described  farther  on.  A  glass  table  in  this  room  serves  for  dressings  and  solu- 
tions, while  in  the  corner  is  an  instrument  closet.  On  the  top  of  this  closet  is 
the  massage  vibrator,  properly  connected  with  the  electric  current ;  the  flexible 
shaft  of  this  instrument  is  sufiiciently  long  to  reach  the  treatment  table. 

In  a  recess  of  this  room  is  an  electric  outfit  for  high-frequency  current, 
for  X-ray  work  and  for  cautery  and  for  other  electrical  appliances.  A  closet 
over  the  washstand  holds  the  stock  for  the  solutions  and  medicines  that  are  used 
in  the  daily  work  in  the  treatment  of  cases.  The  scales,  on  which  patients  are 
weighed  from  time  to  time,  are  also  included  in  the  furnishings  of  this  room. 

Besides  the  examining  table  and  tray  stand  for  the  instruments,  there  is  an- 
other glass-top  table  for  the  apparatus  and  instruments  used  in  the  examination 
and  treatment  of  patients.     This  stands  just  beside  the  examining  table. 

Room  No.  4,  the  next  in  order,  is  of  the  same  size  as  Xo.  3  and  com- 
municates with  the  latter  as  well  as  with  the  corridor.  It  connects  also  Avith 
the  room  behind  it  by  means  of  folding  doors.  It  serves  as  the  second  examin- 
ing and  cystoscopic  room  and  is  used  principally  for  treating  women  and  for 
urethroscopy,  cystoscopy  and  ureteral  catheterization  in  both  sexes.  The  gen- 
eral arrangement  is  the  same  as  Room  Xo.  2,  in  that  it  contains  an  instrument 
cabinet,  washstand,  examination  and  instrument  tables.  The  table  for  examining 
and  treating  patients  is  known  as  the  Allison  (Fig.  130),  which  I  find  unequaled 


AERANGEMENT    OF    AUTHOR'S   PRESENT    OFFICES 


147 


for  cystoscopic  work.  It  seems  to  afford  a  better  position  for  this  purpose  than 
any  other,  as  the  seat  part  of  it  is  shorter  than  that  of  other  tables.  The  illustra- 
tion shows  the  position  of  the  hips  when  this  table  is  nsed  in  cystoscopic  work. 
Each  of  the  examining  tables  is  provided  with  a  detachable  and  adjustable 
pair  of  leg  and  knee  rests,  as  seen  in  the  illustrations.  The  choice  of  these  is 
a  matter  of  individual  preference,  the  knee  rests  having  the  advantage  that  the 
patient  can  be  more  quickly  placed  in  position  than  with  the  straps  attached 
to  the  leg  holders. 


Fig.  130. — Allison  Table  in  the  Cystoscopic  Position,  with  Shoulder  and  Buttock 

Pieces  Elevated. 
Knee  rests  or  lithotomy  uprights  are  used  when  cystoscopy  is  performed. 

In  the  corner  of  Room  ISTo.  4  is  a  washstand  over  which  is  a  closet  for  solu- 
tions, etc.,  the  entire  corner  being  screened  by  a  wdiite,  washable  curtain  swing- 
ing upon  a  hinged  rod.  An  instrument  case  with  glass  shelves  contains  all  the 
instruments  used  in  this  room.  A  glass  table  with  a  shelf  underneath  contains 
all  the  necessary  articles  for  conducting  cystoscopy  and  other  examinations  the 
same  as  in  Room  l\o.  2. 

The  next  room,  No.  5,  separated  from  ISTo.  4  by  folding  doors,  is  known 
as  the  back  office,  and  is  the  assistant's  room,  in  which  correspondence  is  looked 
out  for  and  office  work  attended  to  which  is  not  accomplished  in  the  main  office. 
The  files  for  histories  and  records  are  kept  in  this  room.  Doctors  who  call 
with  their  patients  often  wait  here.  It  is  used  as  a  second  consultation  room 
in  which  to  take  histories  and  interview  patients  when  the  front  office  is  in  use. 
A  ])art  of  the  library  is  here  and  easy  chairs,  and  a  couch  for  patients  who  may 
want  to  rest.  It  forms  wath  Room  No.  4  a  second  consultation  and  treatment 
room  corresponding  to  Rooms  ISTos.  1  and  2. 


148 


UROLOGICAL    EQUIPMENT 


The  last  room  of  the  series  is  the  hiboratory,  No.  6.  Tn  tliis  room  the  lu'ines 
are  examined.  All  the  equi])ment  needed  for  the  examination  is  found  here. 
The  room  contains  waslistand,  draining  boards,  closets  for  chemicals  and  re- 
agents, the  microscopes  and  laboratory  accessories,  A  desk  serves  for  keeping" 
the  records  and  filing  the  laboratory  cards.  Some  of  tlie  interesting  ulceration 
specimens  are  also  kept  here. 


APPOINTMENT    IVO. 


ADDRESS 


DIAGNOSIS 


WILL     COME    ON. 


APPOINTMENT    ^VITII 

DK.    BAMON    GUITEBAS 

80   Madison   Ave. 
New  Yokk 


M. 


HOUR A.   M., 


N.   B.  — Office  visits   are   not   expected  to   last   more    than  a  quarter  of 

an  hour 

No  special  appointments  are  given  in  the  afternoon.     Patients  are  seen 

in  tlie  order  in  which  they  arrive. 


TELEPHONE 
MADISON     SQUARE,     5798 


OFFICE    HOTJES:    0-13    A.  M. 


Fig.  131. — Appointment  Form. 


Office  Management. — A  patient,  calling  for  the  first  time,  on  entering  the 
reception  room  is  handed  a  card  bearing  the  date  of  his  or  her  visit  and  is  in- 
structed to  write  the  name  and  address.  All  old  patients  write  their  names  on 
a  similar  card  at  each  visit.  Whenever  a  patient  arrives,  the  attendant  at  the 
door  telephones  upstairs  announcing  the  arrival,  which  is  immediately  regis- 


OFFICE   MANAGEMENT 


149 


t(M'('(]  l)y  (lie  nurse  in  attendance  on  the  office  floor  on  a  list  that  I  have  always 
before  nie.  The  card  which  has  been  received  in  the  reception  room  is  then 
brought  np  and  placed  on  a  table  in  the  hall.  New  patients  are  shown  up  to 
the  cousultation  room  and  their  histories  are  taken  by  one  of  the  assistants, 
wlio  also  makes  arrangements  regarding  the  fees.  The  patient  is  then  brought 
t(i  me  for  examination,  and  any  specimens  requiring  examination  are  sent  to 
llio  laboratory.  When  the  examination  is  finished,  the  diagnosis  made,  the  treat- 
incut  outlined  and  an  opinion  given,  if  the  patient  is  in  need  of  further  treat- 
ment in  the  office,  an  appointment  is  given  for  the  next  visit.     (See  Fig.  131.) 

The  old  patients,  on  arriving,  are  called  up  and  assigned  to  one  of  the  as- 
sistants with  whom  treatment  is  continued  until  they  are  discharged.  All  pa- 
tients are  seen  by  me  personally  at  each  visit  or  as  often  as  necessary.  At  the 
expiration  of  office  hours,  the  cards  of  new  patients  are  placed  in  the  file  index 
of  ]iatients.  A  card  with  the  name  of  the  physician  recommending  the  case 
is  put  in  another  file,  and  cards  with  the  name  of  the  disease  written  on  them 
are  placed  in  the  third  file.  The  history  is  put  in  an  envelope  and  placed  in  a 
large  vertical  file.  This  gives  a  very  thorough  record  of  the  case.  Very  often 
histories  used  to  lie  about  in 
tlio  office  pending  the  writing 
(if  tlu'  urine  analysis  or  other 
data  and  consequently  no 
diagnosis  of  the  case  was 
written,  no  treatment  out- 
lined and  no  diet  prescribed.  The 
•following  rules  were  therefore  for- 
mulated and  posted  over  the  mi- 
croscope tables  in  the  laboratory. 

Arrangement  of  the  Rules 
roR  THE  History  of  Patients. 
—  (1)  The  history  of  each  patient 
should  be  taken  by  an  assistant. 

(2)  The  patient  should  be  ex- 
amined physically  and  the  find- 
ings written  down.  The  one  Avho 
makes  any  part  of  the  examina- 
tion should  write  it  down  with  his 
initial  after  it. 

(3)  The  urine  goes  to  the 
laboratory  and  is  examined  by  the 
laboratory  man  who  writes  the  urine  report  on  the  examination  card.  It  is  then 
sent  to  me  for  the  diagnosis  and  should  not  be  filed  until  the  diagnosis  is  written 
upon  it. 


Fig.  132. — Three  Vertical  Files  in  Which  the  En- 
velopes Containing  the  Patients'  Histories  and 
Correspondence  are  Kept. 


150 


UROLOGICAL    EQUIPMENT 


If  tliere  is  an  opinion  to  be  given,  it  should  be  written  out  by  me  and 
under  no  circumstances  should  the  history  be  filed  without  this  having  been 

done. 

When  these  letters  of 
opinion  and  diet  are  writ- 
ten, a  carbon  copy  should 
be  made  and  they  should 
be  submitted  to  me  before 
they  are  sent  out. 

All  correspondence  is 
kept  in  the  history  en- 
velope. 

The  management  nf 
the  office  is  entirely  in  the 
hands  of  the  nurse  who 
is  also  secretary.  She  has 
care  of  the  correspondence, 
the  appointments  for  vis- 
its and  operation,  the  pa- 
tients' accounts,  the  laun- 
dry, the  purchase  of  office 
supplies,  the  making  of 
the  dressings,  the  steriliz- 
ing of  the  instruments 
and  dressings  and  the  lists 
of  instruments  and  ap- 
paratus that  leave  the 
office  for  outside  opera- 
tions. 

Equipment  for  Clinic 
and  Hospital. — The  work 
in  the  clinic  corresponds  to 
that  in  the  office  on  a  large 
scale,  although  the  equip- 
ment and  records  are  not 
kept  so  carefully.  There 
are  generally  plenty  of  as- 
sistants, most  of  whom  are 
there  to  learn  the  routine 
of  the  work  of  the  clinic  and  who  are  generally  not  so  well  trained  as  are  office 
assistants. 

The  clinic  records  are,  therefore,  but  about  a  quarter  as  valuable,  except 


Fig.    133. —  Plan   of   the    Clinic   at   the    New    York   Post- 
graduate Medioal  School. 

1,  waiting  room  for  old  patients. 

2,  waiting  room  for  new  patients. 
S,  passage  to  Rooms  4,  5,  6,  and  7. 

In  the  corner  of  Room  3  is  seen  a  table  and  chair  where  the 
history  file  is  kept  by  the  historian.  The  room  to  the  left  of 
Room  4  is  for  the  acute  cases.  Room  5  is  the  room  for  chronic 
cases.  Room  6  is  the  cystoscopic  room.  Room  7  is  the  amphi- 
theater. Each  of  these  rooms  has  two  treatment  tables,  an  in- 
strument table  and  a  sterilizer. 


EQUIPMENT   FOR    CLINIC    AND    HOSPITAL  151 

so  far  as  a  record  for  tlie  number  treated  is  concerned.  Tlie  greatest  difficulty 
is  fonnd  in  obtaining  assistants  with  the  true  scientific  spirit  who  are  willing 
to  give  their  time  to  tabulating  statistics,  to  investigating  new  methods  and  to 
doing  research  work  outside  of  the  clinic. 

The  plan  of  the  clinic  (Fig.  133)  is  that  of  a  semicircle  and  is  arranged  as 
follows : 

No.  1  is  the  general  waiting  room.  No.  2  is  the  waiting  room  for  new  pa- 
tients. No.  3  is  the  passage  in  which  the  records  are  kept.  No.  4  is  the  first- 
treatment  room.  No.  5  is  the  second-treatment  room.  No.  6  is  the  cystoscopic 
room  and  No.  7  is  the  amphitheater  or  lecture  room.  The  old  patients  enter  in 
tlie  basement  Room  1 — the  new  ones  are  brought  into  Room  2  where  they  wait 
for  the  lecture. 

Room  3  is  the  passage  and  here  is  the  table  at  which  the  card  index  is  kept. 
The  clinic  filer,  w^ho  sits  at  this  point,  directs  the  new  patients  to  enter  from 
Room  2  for  the  lectures  and  the  old  patients  come  in  from  Room  1  to  be  treated 
in  the  other  rooms.  The  card  filer  hands  the  cards  to  the  patients  as  they  come 
in  and  replaces  them  when  they  pass  out.  The  first  assistant  investigates  the 
new  patients  before  they  go  to  the  lecture  room,  writing  down  their  names  and 
l)rincipal  symptoms,  and  brings  the  list  into  the  lecture  room  (No.  7).  The  lec- 
turer reads  over  the  list  and  has  the  cases  sent  in  as  chosen.  The  patient,  on 
entering,  is  placed  on  the  table,  his  history  is  taken  aloud  by  the  lecturer,  and 
recorded  by  the  historian.  The  local  examination  is  then  made  by  inspection 
and  palpation. 

If  the  patient  is  an  acute  case,  there  is  usually  but  little  difficulty  in  making 
a  diagnosis.  If  the  case  is  chronic,  however,  the  patient  is  instructed  to  leave 
the  table  and  pass  his  urine  in  two  glasses.  The  first  and  second  specimens  are 
inspected  and  the  appearance  noted,  after  which  the  patient  leans  over  the  table 
and  the  prostate  gland  and  seminal  vesicles  are  examined.  The  patient  then 
passes  the  remainder  of  his  urine,  containing  any  debris  that  has  been  expressed 
from  the  internal  genitals  during  examination.  The  three  specimens  are  then 
handed  to  the  microscopist,  seated  at  the  table,  for  examination.  While  he  is 
attending  to  this,  the  patient  is  again  placed  on  the  table  and  the  lecturer  pro- 
ceeds to  examine  the  urethra  with  the  instruments  at  hand.  As  the  instruments 
are  used,  they  are  handed  to  an  assistant,  Avho  attends  to  the  sterilization. 

After  the  patients  have  been  examined  and  the  diagnoses  made,  they  are 
each  referred  to  a  certain  clinical  assistant  outside,  whose  patients  they  then 
become  and  who  are  treated  by  him  until  cured,  unless  some  complication  oc- 
curs or  the  assistant  in  charge  of  the  case  desires  him  to  come  again  before  the 
lecturer.  All  the  acute  cases  are  sent  to  the  first-treatment  room  (No.  4)  and 
are  placed  in  the  care  of  the  two  assistants  in  charge  of  this  room.  All  chronic 
cases  are  sent  to  the  second-treatment  room  (No.  5),  in  which  there  are  also 
two  assistants  working.     When  an  acute  case  becomes  chronic,  the  physician  in 


152  UKOLOGICAL  EQUIPMENT 

charge  can  either  continue  treating  him  or  else  refer  him  to  the  room  for  the 
chronic  cases.  In  both  these  rooms,  there  are  two  treatment  tables,  an  instru- 
ment and  a  sterilizing  table  and  some  chairs.  The  instruments  are  of  the  same 
variety  as  those  used  in  the  office. 

Room  6  is  the  cjstoscopic  and  bladder  room.  In  this  are  two  tables,  on  one 
of  wdiich  the  patients  are  prepared  for  cystoscopy,  while  on  the  other  they  are 
examined  by  the  cystoscopist.  As  the  preparation  for  cystoscopy  takes  some 
time,  the  case  lectured  on  is  not  prepared  in  the  amphitheater,  but  outside,  after 
wdiich  the  patient  is  wdieeled  into  the  lecture  room  wdth  the  cystoscope  in  the 
bladder,  ready  for  examination.  This  is  the  usual  routine,  but  in  cases  in 
which  the  fluid  medium  becomes  rapidly  turbid,  as  in  marked  pyuria  and  hciua- 
turia,  the  last  Avashing  is  given  in  the  lecture  room  and  the  cystoscope  is  then 
introduced. 

The  clinic  is  managed  by  a  chief  of  clinic,  who  goes  about  from  room  to 
room  and  gives  help  and  advice  to  the  clinical  assistants.  Clinic  patients 
are  in  charge  of  the  first  assistant.  One  man  is  at  the  head  of  the  cys- 
toscopic  room,  and  two  in  each  of  the  treatment  rooms,  the  man  Avho  has 
had  the  longest  duty  outranking  the  other  in  each  of  the  rooms.  The  rec- 
ords are  in  charge  of  two  men,  one  in  the  lecture  room  who  takes  all  the  his- 
tories, the  other  on  the  outside  who  makes  notes,  at  each  lecture,  of  the  inter- 
esting cases  that  are  kept  under  observation,  such  as  the  kidney,  bladder  and 
stricture  cases,  as  well  as  those  who  are  to  be  operated  or  have  already  been 
operated  upon. 

The  new  men  coming  to  assist  the  clinic  go  through  a  regular  circle  of  serv- 
ices before  they  are  permanently  appointed  clinical  assistants,  serving  in  each 
for  at  least  three  months.  The  rotation  is  as  follows:  Historian  in  the  aiiii)hi- 
theater;  first-treatment  room,  treating  the  acute  cases;  second-treatment  riKHu, 
treating  the  chronic  cases ;  third-treatment  room,  working  in  cystoscopy.  When 
they  have  finished  cystoscopy,  if  fitted  for  it,  they  go  on  the  microscope,  other- 
wise they  go  on  the  book  and  around  the  circle  again,  as  the  head  man  of  the 
different  departments. 

The  development  of  the  clinic  and  of  the  clinical  assistant  has  been  very 
satisfactory  of  late,  owing  principally  to  the  formation  of  an  Alumni  Society, 
that  meets  once  a  month,  at  each  of  which  meetings  one  of  the  assistants  reads 
a  thesis  on  some  subject  that  has  been  assigned  as  a  special  w^ork. 

The  hospital  is  connected  with  the  clinic,  inasmuch  as  the  patients  requiring 
operation  are  referred  to  the  hospital  for  the  operation  clinic,  which  takes  place 
once  a  w^eek.  After  they  recover,  they  are  again  sent  to  the  clinic  for  observa- 
tion and  treatment.  Patients  are  also  referred  to  the  hospital  for  treatment, 
although  it  is  principally  for  an  operative  service.  The  same  instruments  and 
apparatus  are  used  at  the  hospital  and  for  outside  work,  as  have  already  been 
indicated  under  Equipment  for  the  Office. 


CHAPTEK    VII 

STERILIZATION   OF  INSTRUMENTS  AND   APPARATUS 

The  methods  of  destroying  germs  applicable  to  urological  instruments  are : 
Disinfection  by  means  of  chemicals,  by  boiling,  by  steam,  and  by  the  vapors  of 
bactericidal  snbstances.  It  is  important  to  know  the  particular  method  which 
is  suitable  for  each  special  class  of  instruments,  as  some  appliances  are  injured 
by  subjecting  them  to  the  wrong  process.  Probably  the  most  efficient  method 
of  disinfecting  an  instrument  that  can  be  sterilized  by  any  method  is  by  boiling 
or  steam.  The  least  effective  of  the  methods  at  our  disposal  is  disinfection  in 
chemical  solutions,  a  method  which  is  used  chiefly  in  emergencies.  Disinfection 
with  chemical  vapors  is  more  thorough  and  more  trustworthy  than  with  solutions, 
and  the  vapors  of  formalin  have  now  been  adopted  very  generally  in  the  dis- 
infection of  urological  instruments  which  do  not  bear  the  application  of  heat. 

Chemical  Solutions. — Formerly  it  was  considered  sufficient,  for  all  practical 
purposes,  to  disinfect  certain  urological  instruments,  such  as  catheters,  by  im- 
mersing them  in  solutions  of  carbolic  acid  or  bichlorid  of  mercury.  It  has  been 
shown,  however,  that  these  methods  are  untrustworthy,  and  that  even  when 
catheters  are  immersed  for  half  an  hour  in  a  1 :  1,000  solution  of  bichlorid, 
living  microorganisms  have  been  found  within  their  lumen. 

Of  the  solutions  which  are  employed  with  more  or  less  safety  in  the  steril- 
izations of  urological  instruments,  we  may  mention  formalin  and  mercuric 
oxycyanid,  the  latter  1 :  1,000  to  1 :  500.  Formalin  is  probably  the  better  of 
the  two,  and  can  be  used  in  a  strength  of  from  two  to  five  per  cent.  The  most 
convenient  solution  of  formalin  is  that  recommended  by  Holtzein,  which  serves 
for  the  disinfection  of  cystoscopes,  urethroscopes,  woven  catheters,  etc.  The 
stock  solution  consists  of  sixty  parts  of  formalin  and  forty  parts  of  alcohol. 
Two  drachms  of  this  solution  are  added  to  each  pint  of  distilled  water  for  im- 
mediate use. 

]\[ercuric  oxycyanid  is  employed  in  the  strength  of  1 :  200  for  the  dis- 
infection of  delicate  instruments,  such  as  cystoscopes,  etc.  The  value  of  this 
sidistance  is  rather  questionable. 

Boiling. — Boiling  is  one  of  the  best  ways  of  attaining  absolute  asepsis.  The 
material  to  be  boiled,  however,  must  be  carefully  selected.  Metallic  instru- 
ments, consisting  entirely  of  metal  or  of  glass  or  the  two  combined,  may  be 

153 


154 


STERILIZATION   OF   INSTRUMENTS   AND   APPARATUS 


l)oilc(l  with  impunity.     It  is  always  liest  to  add  some  soda  to  the  water,  so  as 
to  prevent  rnsting  and  to  preserve  the  nickel  plating.      Soft-rnbljer  catheters 

may  also  be  boiled,  Ijut  plain  Avater 
should  be  used.  The  time  required 
for  boiling  any  of  these  classes  of 
instruments  is  five  minutes.  Any 
instrument  boiler,  fish  boiler,  or 
common  agate  or  enameled  pan, 
can  be  used.  Special  long  and  nar- 
row pans  with  covers  are  useful  for 
boiling  soft  rubber,  glass  or  metal 
instruments  in  the  office  or  the 
treatment  room. 

Steam. — When  employed 
correctly,  steam  under  pres- 
sure disinfects  with  the  same 
efficiency  as  boiling.  The 
steam  must  penetrate  through 
every  part  of  the  material  to 
be  disinfected,  and  the  time 
of  exposure  must  be  sufficient 
to  kill  the  most  resistant 
germ ;  that  is,  about  twenty- 
five  minutes.  Disinfection 
with  steam  requires  special 
apparatus,  although  in  an 
emergency  an  ordinary  fish 
kettle,  with  a  perforated  pan  hanging  over  the  boiling  water,  can  be  employed. 
One  of  the  best  all-round  steam  sterilizers 
is  that  known  as  the  ''Willy  Meyer"  (Fig. 
134).  This  can  be  used  for  both  dressings 
and  instruments,  and  is  very  convenient 
for  carrying  to  an  operation  at  the  patient's 
house.  Another  of  about  the  same  size, 
though  a  more  complicated  sterilizer,  is 
the  type  known  as  "  Rochester  Combina- 
tion "  (Fig.  135).  In  this  sterilizer,  we 
can  use  alternately  steam  and  dry  heat,  so 
that  the  steamed  articles  can  be  dried  by 
heat  without  removing  them  from  the 
trays.  Both  these  sterilizers  have  an  arrangement  for  boiling  instruments  in 
the  water  which  produces  the  steam. 


I 


Fig.  134.- 


-WiLLY  Meyer  Sterilizer  for  the  Sterilization 
OF  Dressings  and  Instruments. 


Fig.  135. — Rochester  Sterilizer. 


FORMALIN   VAPORS 


155 


Formalin  Vapors. — Formalin  vapors  offer  a  very  convenient,  and  at  the 
same  lime  very  ettieieut,  way  of  disinfecting  all  kinds  of  urological  instruments, 
especially  cystoscopes,  Avoven  catheters,  etc.  The  most  convenient  apparatus 
for  this  pur])ose  is  Schering-Glatz's  formaldehyd  sterilizer  (Fig.  136). 

This  apparatus  consists  of  a  box  of  japanned  tin,  measuring  18  x  11-|  x  8 
inches.  It  has  two  shelves  upon  which  the  instruments  may  he  placed,  and  a 
small  compartment  for  the  formahlehyd  lamp.  One  side  of  this  box  swings 
on  hinges,  forming  a  door  of  sufficient  size  for  the  introduction  of  the  longest 


Fic 


136. — Formalin  Sterilizer,  Used  Principally  for  Woven  Catheters,  Piston  Syringes  and 

Cystoscopes. 


instruments  that  the  box  will  hold.  The  lamp  is  about  eight  inches  high,  con- 
sisting of  a  body  for  the  alcohol  and  a  chimney,  in  the  top  of  which  is  a 
cup  or  receptacle  for  formalin  pastilles,  white  tablets  which  by  heat  are  com- 
pletely converted  into  formaldehyd  gas.  The  strength  of  each  pastille  is  five 
grains.  Two  of  these  tablets  are  sufficient  for  ordinary  disinfection  in  this 
apparatus. 

The  instruments  are  placed  on  the  wire  shelves.  Two  five-grain  paraform 
pastilles  are  put  into  the  cup  or  receptacle.  The  lamp  is  now"  lit  and  the  door 
closed.  A  small  glass  window  in  the  door  permits  us  to  watch  the  flame  of  the 
lamp.  An  outlet  at  the  top  of  the  box  allows  the  escape  of  gas  when  steriliza- 
tion is  complete.  The  lamp  will  burn  for  twenty  minutes  in  the  air  of  the  box, 
when  empty.  About  ten  minutes  are  needed  to  burn  a  five-grain  pastille  of 
})araform  in  the  sterilizer.  Ten  minutes'  exposure  to  the  amount  of  gas  obtained 
by  vaporizing  two  five-grain  pastilles  will  kill  anthrax,  diphtheria,  tubercle  and 
typhoid  germs,  as  well  as  those  of  suppuration.  At  my  suggestion.  Prof.  H.  T. 
Brooks,  of  the  Post-Graduate  Hospital,  made  a  series  of  experiments  with  this 


156  STERILIZATION   OF   INSTRUMENTS   AND   APPARATUS 

sterilizer  to  determine  its  efficiency.  The  following  is  an  extract  from  his 
report,  which  was  sent  to  me  in  December  17,  1899. 

Woven  catheters  were  injected  with  dilutions  of  live  cultures  of  the  typhoid, 
colon  and  prodigiosus  bacilli,  and  the  Staphylococcus  aureus.  The  catheters 
were  then  drained,  dried,  and  placed  in  the  Schering  formalin  sterilizer.  Two 
pastilles  were  burned  for  ten  minutes,  after  which  the  lamp  flame  was  spon- 
taneously extinguished.  The  door  of  the  sterilizer  was  then  opened,  two  new 
pastilles  placed  in  the  cup  above  the  lamp  chimney,  the  lamp  relighted,  and  the 
door  closed.  The  lamp  Avas  then  allowed  to  burn  for  an  additional  ten  minutes. 
The  door  was  not  oj3ened  until  a  third  ten  minutes  had  elapsed — i.  e.,  thirty 
minutes  from  the  beginning  of  the  exposure.  The  catheters  were  then  removed 
from  the  chamber  with  sterile  forceps,  cut  with  sterilized  scissors,  and  portions 
placed  on  gelatin  plates,  in  tubes  of  alkaline  bouillon,  and  also  in  surface  and 
submerged  agar  tube  cultures.  jSTo  growth  of  any  of  the  above-mentioned  organ- 
isms occurred  after  three  days  in  the  incubator  at  98^  F.  Control  cultures 
were  made  from  the  original  dilutions  used  for  injecting  the  catheters,  and  all 
grew. 

Subsequent  experiments  showed  that  the  tubercle  bacillus  and  the  strepto- 
coccus also  were  killed  by  exposure  to  the  formalin  fumes  for  half  an  hour. 

Detailed  Methods  of  Sterilization  and  Disinfection: 

1.  Water. 

2.  Surgeon's  hands, 

3.  Rubber  gloves. 

4.  Packages  of  dressings  and  tubes  of  gauze. 

5.  General  care  of  instruments. 

6.  Catheters. 

1.  Cystoscopes,  urethroscopes,  etc. 

8.  Piston  syringes. 

9.  Glass  hand  syringes. 

10.  Instillation  syringes. 

11.  Hypodermic  syringes  and  needles. 

12.  Glass  and  agate  ware,  etc.;  infusion  jars;  irrigator  jars  and  tips; 

pans,  pus  basins,  pitchers,  dishes,  trays  and  glass  jars. 

13.  Catheter  lubricants. 

Snell's  formaldehyd  sterilizer  is  recommended  for  catheters  (Fig.  137). 

1.  Water. — The  quality  of  the  water  used  in  the  office  for  making  our 
solutions  was  found  unsatisfactory.  It  was  ordinary  boiled  city  water  and 
at  times  was  discolored  and  often  formed  some  chemical  combination  with  silver 
or  other  salts  used  for  solutions.  Besides  this,  the  enamel  was  burned  off  the 
bottom  of  the  kettle,  giving  rise  to  a  certain  amount  of  mineral  deposit  in  the 
water.    When  this  occurred  in  the  instrument  sterilizer,  which  was  of  the  same 


METHODS    OF    STERILIZATION   AND   DISINFECTION 


157 


constrnction  as  the  kettle,  a  gritty  substance  climg  to  the  instruments,  while  a. 
scum  floated  on  the  water.     For  a  long  time  we  used  filtered  water,  which  had 
been  boiled,  but  even  filtered  water  formed  a  chemical  combination  or  gave 
rise  to  precipitates.     We  then  began  to  use  distilled  water,  which  has  proved 
iiiost  satisfactory. 

In  the  smaller  towns,  this  can  be  made  in  the  oflico  with  the  aid  of  a  still, 
such  as  are  now  used  for  its  rapid  manufacture.  In  the  large  cities  we  simply 
buy  distilled  water  in  five-gallon  bottles.  The  water  is  heated  in  a  large  tea 
kettle,  which  should  be  changed  for  another  as  soon  as  it  is  burned  in  the  least 
(legTce. 

After  the  distilled  water  has  been  heated,  it  is  poured  into  an  aseptic  pitcher 
and  thence  into  an  earthenware  jar  with   a  faucet  in  the  lower  part.      The 


Fig.  137. — Snell's  Fokmalin  Sterilizer  for  Sterilizing  all  Catheters, 

BUT  especially  URETERAL. 

The  catheters  are  pushed  over  hollow  posts  leading  to  the  formalin  chamber. 

sterilized  water  is  drawn,  as  needed,  from  this  jar.  The  kettle  is  always  kept 
full  of  hot  water  in  order  to  replenish  the  treatment-room  jar  whenever  neces- 
sary. The  cooled  water  is  drawn  off  into  a  second  jar,  which  is  kept  beside  the 
one  for  hot  water  in  order  to  mix  the  two  for  solutions  at  a  proper  temperature. 
An  extra  supply  of  cold  sterilized  water  is  kept  in  sterile  flasks,  stoppered  with 
cotton  or  gauze. 

2.  Surgeon's  Hands. — The  care  of  the  hands  is  one  of  the  most  important 
details  in  a  urological  office.  It  is  a  problem  how  to  keep  the  hands  clean,  as 
they  are  constantly  touching  septic  matter.  Each  treatment  room  should  be 
provided  with  soap,  brushes,  nail  cleaners  and  jars  of  bichlorid  for  the  hands. 

3.  Rubber  Gloves. — At  intervals  I  have  worn  rubber  gloves,  but  have 
never  become  accustomed  to  them  in  office  work.     There  is  so  much  changing 


158 


STERILIZATION   OF   INSTRUMENTS   AND   APPARATUS 


of  clothes,  telephoning,  handshaking,  prescription  writing  and  other  matters 
of  a  business  and  social  nature  transacted  during  office  hours,  that  the  changing 
of  gloves  becomes  a  difficulty  and  involves  a  great  loss  of  time.  The  surgeon 
should,  however,  wear  rubber  gloves  in  the  treatment  of  all  cases  which  tlireaten 
infection.  In  the  office,  they  are  washed  with  soap  and  water,  wrapped  in  a 
towel,  and  boiled  for  ten  minutes  after  using  them,  then  dried,  powdered  and 
wrapped  in  gauze  and  put  away  until  next  needed. 

4.  Packages  of  towels^  gauze  compresses,  sponges  or  pads,  gauze  band- 
ages, cotton  balls,  sanitary  pads,  muslin  table  covers  and  sheets  should  be 
sterilized  by  steam.  Strips  of  j)lain  gauze,  for  packing,  should  be  sterilized 
in  the  tubes  in  which  they  are  kept. 

5.  General  Care  of  the  Instruments  After  Using. — After  use,  all 
instruments  should  be  washed  in  hot  water  and  green  soap  with  a  soft  brush 

or  piece  of  gauze,  thoroughly  dried  and 
put  away.  Special  care  should  be  taken, 
in  the  case  of  cystoscopes,  not  to  sub- 
merge the  entire  instrument  in  cleaning 
or  other  solutions.  Metal  instruments 
should  be  cleaned  in  the  same  manner  as 
house  silver,  when  they  begin  to  tarnish. 
All  instruments  should  be  kept  free  from 
dust  in  closed  cabinets,  or  between  towels 
if  on  open  shelves. 

6.  Catheters. — It  is  very  difficult  to 
clean  catheters  and  other  hollow  instru- 
ments, as  the  remnants  of  pus,  mucus 
and  blood  are  apt  to  remain  adherent  to 
their  interior.  This  is  especially  true 
when  greasy  lubricants  have  been  used. 
A  catheter  must  be  flushed  out,  after 
using  it,  with  soapsuds,  by  means  of  a 
piston  syringe,  or  by  attaching  to  a  sink 
faucet  a  small  nozzle  which  will  iit  into 
the  lumen  of  the  catheter.  In  this  way, 
a  strong  jet  of  water  can  be  made  to  flow 
tlirough  it  (Fig.  138).  This  is  most 
important  especially  in  woven  catheters, 
which  are  usually  sterilized  by  means  of 
gas    or    chemical    solutions    that    do    not 

penetrate  a  coat  of  dried  albuminous  matter  containing  infection  that  adheres  to 

their  inner  walls. 

Soft-rubber    catheters    are   best    sterilized    b}'    boiling   for    ten   minutes    in 


Fig.  138. — Method  of  Flushing  out  Cathe 
TERS  Employed  in  Author's  Office. 


METHODS    OF    STERILIZATION   AND   DISINFECTION 


159 


])lain  water  after  a  thorougli  cleansing.     They  should  be  wrapped  in  ganze  or 
a  towel  and  put  into  the  boiler  so  that  they  do  not  come  in  contact  with  the  wall 


of  the  boiler  and  become  burned. 


In  the  office,  we  boil  our  catheters  in  bags 


Fig.  139. — Catheter  and  Catheter  Tube. 


and  then  put  the  bags  into  glass  tubes.     In  this  way  they  are  handled  more 
easily  than  in  the  wet  bags  alone  (Fig.  139). 

Woven  urethral  and  ureteral  catheters  cannot  be  boiled  or  placed  in  carbolic 
acid.  They  may  be  sterilized  either  by  immersing  them  for  thirty  minutes  in 
a  solution  of  silver  nitrate  or  of  mercuric  oxycyanid  (1:1,000),  or  else  by 
exposing  them  to  the  vapors  of  formaldehyd  in  the 
formalin  sterilizer.  The  last-named  method  is  the 
best  and  is  the  one  used  in  the  office. 

Another  way  of  sterilizing  woven  catheters  by 
formaldehyd,  consists  in  placing  them  in  a  glass 
tube,  in  the  stopper  of  which  is  a  rubber  receptacle 
containing  formalin  tablets  (Fig.  110).  The 
lower  part  of  the  stopper  is  perforated  and 
through  these  perforations  the  vapors  of  formalin 
are  constantly  passing  into  the  tube.  They  can 
also  be  placed  in  boxes  in  the  center  of  which  is  a 
piece  of  gauze  containing  tablets  or  a  j)Owder  of 
formalin.  The  formaldehyd  gas  is  spontaneously 
generated  and  sterilizes  the  catheters  in  twenty- 
four  hours.  Special  boxes  are  constructed  for  this 
])iirpose,  although  any  ordinary  flat  air-tight  tin 
box  will  do  as  well. 

7.  Cystoscopes,  urethroscopes  and  other 
delicate  instruments  of  this  type  are  sterilized  in 
the  fornuilin  sterilizer.  After  being  used,  the 
outer  surface  of  the  shaft  is  washed  with  tincture 
of  green  soap  and  water  by  means  of  a  piece  of 
gauze,  then  with  alcohol,  after  which  they  are  laid 
away  in  their  cases,  or,  better  still,  wrapped  in  gauze,  ready 
any  moment. 

8.  Piston  syringes  of  large  size    that  is,  holding  from  four  to  six  ounces. 


Fig.  140. — Tubes  with  Hollow 
Rubber  Stoppers  Containing 
Formalin. 


he  sterilized  at 


160  STERILIZxVTIOX   OF    INSTRUMENTS   AND   APPARATUS 

such  as  are  used  for  washing  out  the  bladder,  are  usually  made  of  hard  ruhber, 
metal  or  glass  and  metal.  They  are  best  sterilized  with  formalin  gas  in  the 
Schering  sterilizer.  The  metal  syringes  and  those  of  glass  and  metal  can 
also  be  boiled.  They  may  be  sterilized  in  clieiiiical  solntitms  the  same  way 
as  the  woven  catheters,  but  they  are  better  sterilized  in  the  chemical  vajjor 
(formalin). 

9.  Glass  hand  syringes  are  usually  kept  in  jars  with  cotton  in  the  Ijottom, 
partly  filled  with  five-per-cent  carbolic  or  a  1 :  500  bichlorid  solution  and  ])laced 
nozzle  down.  I  keep  mine  in  alcohol  and  rinse  them  with  sterile  water,  as  then 
no  deposits  form  on  the  instruments  that  will  make  chemical  combinations  with 
the  salts  in  the  solutions  used.  Another  good  way  is  to  keep  them  in  water 
and  boil  before  using  them, 

10.  Instillation  Syringes,  Aspirators,  etc. — These  are  sterilized  in 
the  same  way  as  the  large  piston  syringes.  The  instillation  metallic  catheters 
are  boiled  before  being  used. 

11.  Hypodermic  Syringes  and  jSTeedles. — Hypodermic  needles  should 
be  boiled  before  using.  The  needles  are  kept  in  a  small  glass  box  con- 
taining a  powder  made  of  equal  parts  of  boric  acid  and  lycopodium,  always 
with  their  wires  passed  through  their  lumen.  Two  small  glasses,  one  f(jr  a 
five-per-cent  carbolic  solution,  the  other  for  sterile  water,  are  kept  on  a  tray 
on  a  shelf,  called  the  emergency  shelf,  during  the  office  hours ;  also  one- 
ounce  bottles  of  atropin  solution  (10  drops  equal  to  yxo  of  a  gTain)  ;  of 
camphor  in  oil  (10  drops  equal  to  2  gTains)  ;  of  strychnin  sulphate  (10 
drops  equal  to  yV  of  a  grain)  ;  and  pearls  of  amyl  nitrate,  each  containing 
3  grains,  in  a  cotton-lined  box.  These  should  also  be  kept  at  hand  on  a 
table  in  hospitals  and  outside  operations  in  case  of  emergency.  A  little 
glass  receptacle  with  a  cover  contains  cotton  balls  in  ninety-five-per-cent 
alcohol. 

For  local  anesthesia,  special  solutions,  which  are  prescribed  in  the  appro- 
priate chapter,  are  kept  on  a  tray  with  special  syringes  and  needles,  arranged 
in  a  similar  manner  to  the  hypodermic  tray  just  described.  (See  chapter  on 
Anesthesia.) 

12.  Miscellaneous  Articles  of  Hard  Rubber,  Glass,  Porcelain  and 
Agate  Ware. — Irrigator  tijJS  and  couplings  of  glass  Or  hard  rubber,  to  be  used 
with  rubber  tubes  and  catheters,  are  kept  in  glass  jars  containing  bichlorid 
solution. 

Irrigator  jars  should  be  washed  out  daily  and  flushed  out  with  1 :  1,000  bi- 
chlorid solution. 

Infusion  jars  are  an  important  part  of  the  operative  outfit  and  should 
hold  two  quarts ;  a  thermometer  is  provided  for  each.  They  are  kept  filled 
with  bichlorid  solution  and  are  cleansed  with  sterile  water  before  using.  The 
tubes,  cannulas,  etc.,  are  kept  wrapped  in  a  towel,  sterile  and  ready  for  instant 


METHODS    OF    STERILIZATION   AKD   DISINFECTION  161 

use.  Two  bottles  of  sterile  salt  solution,  one  drachm  to  the  pint,  are  kept  at 
hand  for  use  with  this  apparatus. 

Pans,  pitchers,  pus  pans,  dishes,  basins,  trays  and  glass  jars  should  be 
divided  into  classes,  those  for  aseptic  cases  and  those  for  septic.  Pitchers, 
basins  for  solutions  or  sterile  water,  instrument  pans,  trays,  glasses  for  solutions, 
etc.,  sliould  be  thoroughly  washed  and  cleaned  with  soap  and  water,  rinsed  out 
and  \)ut  into  a  tank,  or  an  unpa luted  waslitul^,  wliero  tliey  are  kept  STdjmerged 
in  1  :  .500  bichlorid  solution.  If  they  are  not  to  be  used  immediately,  they  are 
kept  bottom  up  on  glass  shelves  or  wrapped  in  sterile  towels.  Glass  jars  in 
which  dressings  are  kept  are  cleaned  in  the  same  way  and  should  be  kept  in  the 
l)iehlorid  solution,  with  their  covers  on,  for  an  hour,  and  then  dried  with  a 
sterile  towel. 

Pans  for  the  reception  of  dressings  which  have  been  removed,  pus  j^ans  or 
basins,  urine  tubes  and  all  other  soiled  articles  of  this  order  should  be  scrubbed 
with  soap  and  water,  rinsed  with  bichlorid  and  kept  in  their  customary  places 
without  further  attention. 

13.  LuBRicAiSTTS  FOR  I]srsTKrME]\"Ts. — The  lubricants  generally  employed 
for  urinary  instruments  include  petroleum  bases  (vaselin),  oils,  glycerin  and 
vegetable  bases.  Vaselin  should  never  be  used,  except  for  rectal  examinations. 
Olive  oil  should  be  used  only  after  sterilizing  it  thoroughly  by  allowing  the  un- 
corked bottle  to  stand  in  boiling  water  until  the  oil  itself  boils.  The  only  cases 
in  which  olive  oil  is  useful  is  in  examination  for  a  supposedly  impassable  stric- 
ture. Certain  oils  are  prepared  with  an  antiseptic,  as  gommenol,  which  is  a 
preparation  of  olive  oil  and  eucalyptol. 

The  usual  lubricant  employed  in  both  hospital  and  office  work  is. 'glycerin. 
This  is  kept  in  tall  jars,  into  which  sterilized  instruments  can  be  easily  dipped. 
Glycerin  is  easily  kept  sterile,  as  germs  do  not  thrive  in  it.  Some  surgeons  use 
boro-glycerid,  which  is  a  compound  of  boric  acid  and  glycerin,  containing  thirty 
per  cent  of  the  former.  Personally,  I  do  not  care  for  it,  as  it  sometimes 
irritates. 

The  vegetable  bases,  which  have  of  late  years  been  employed  for  lubricants, 
are  composed  chiefly  of  tragacanth,  or  of  Irish  moss  (chondrus,  carragheen). 
These  bases  have  the  advantage  of  being  soluble  in  water  and  sufficiently  slip- 
pery to  be  an  efficient  lubricant. 

They  are  easily  washed  off  from  the  instruments  or  washed  out  of  the  canal. 
Most  of  the  lubricants  now  on  the  market  contain  such  a  base,  and  have  added 
to  them  either  boric  acid,  eucalyptol,  thymol,  formalin,  etc.,  as  antiseptics. 
They  are  usually  put  up  in  collapsi])le  tubes  with  a  nipple-shaped  nozzle  which 
can  be  used  to  introduce  the  lubricant  into  the  urethra  before  ]")assing  sounds. 
The  nozzle  can  be  sterilized  In'  boiling,  or  each  patient  should  have  his  own 
tube  of  lubricant.  The  lubricant  that  I  use  in  the  office  is  nuide  according  to 
the  following  formula : 


162  STERILIZATION   OF   INSTRUMENTS   AND   APPARATUS 

I>   Tragacantli oss ; 

Glycerin   ovijss ; 

ITydrarg.   Oxjcyanid ors.  i j ; 

Aqiise oiij- 

The  objection  to  oil  and  vaselin  in  urethral  work  is  that  they  leave  a  coating 
over  the  mucous  membrane  of  the  urethra  and  thus  prevent  the  thorough  medi- 
cation of  the  canal  afterwards. 


CHAPTER    VIII 


TECHNIQUE   OF  INSTRUMENTATION 


CATHETERS 

A  CATHETER  IS  a  hollow  tube  with  an  opening  at  one  end  the  size  of  its 
himen,  while  at  the  other  end  the  opening  is  smaller  and  called  the  "  eye."  This 
is  either  in  the  tip  or  near  it. 

Shape  of  Catheters. — The  shape  of  the  catheter  is  either  straight  (Fig, 
141),  or  elbowed  (Fig.  142)  or  curved  (Fig.  143).  The  straight  has  the  same 
caliber  throughout,  or  else  it  tapers  into  the  neck  and  then  widens  out  at  the 

end   forming   a   small   olive-shaped 
dilatation  (olivary  tip)  (Fig.  144). 


Fig.  141. — Straight  Cath- 
eter WITH  Single  Eye, 

USUALLY     OF     THE     SoFT- 

RUBBER  Variety. 


Fig.  142. — Elbowed.Coude 
OR  Mercier  Catheter 
WITH  THE  Eye  on  the 
Side,  usually  of  the 
Woven  Variety. 


Fig.    143. — Curved    Catheter   of   the 
Woven  Variety. 
Not  much  used. 


The  neck  is  the  narrowest  part  of  the  instrument,  while  the  olive-shaped 
end,  though  larger  than  the  neck,  is  smaller  than  the  shaft. 

Elbowed  catheters  have  a  curved  beak,  somewhat  similar  to  that  of  a  sound, 
but  shorter  and  more  angular.  They  are  also  called  coude  or  Mercier  catheters. 
When  the  beak  has  a  double  curve,  it 
is  called  bi-coude  (Fig.  145).  Curved 
catheters  are  shaped  like  sounds. 


Fig.  144. — Straight  Olive-tipped  Woven 
Catheter. 


Fig.   145. — Bi-coude  Woven  Catheter. 
163 


164 


TECHNIQUE    OF    INSTRUMENTATION 


Catheters  are  made  of  soft  riibLor,  of  a  woven  material  with  a  varnish  fin- 
ish, or  of  metal.     Those  made  of  other  material  are  not  recommended. 

The  Eye  of  the  Catheter. — The  eye  of  the  catheter  is  the  openinjij  through 
which  the  water  escapes  into  the  urethra  or  bladder.     It  is  more  frequently  on 

the  side,  the  end  o])ening  be- 
ing confined  principally  to 
instillating  and  large  peri- 
neal drainage  catheters. 

Openings  on  the  side 
may  be  either  single  or  mul- 
tiple. The  single  opening  is 
most  common,  usually  oval  in 
shape  and,  especially  in  the 
soft-rubber  variety,  situated 
about  a  quarter  of  an  inch 
from  the  tip  (Fig.  146). 
The  edges  are  rounded,  so 
they  may  not  give  rise  to 
traumatism  of  the  canal. 
Such  a  finish  is  frequently 
spoken  of  as  the  "  velvet 
eye."  Straight  catheters, 
whether  they  are  soft 
rubber     or     woven,     usually 


Fig.  146. 


Fig.  147. 


have  but  one  eye.  In  the  olivary  type  of  woven  catheter,  the  eye  is 
situated  in  the  body  of  the  catheter,  and  may  be  one  inch  or  more  from 
the  tip. 

In  the  elbowed  catheter,  when  made  of  soft  rubber,  the  opening  is  usually 
made   in   the   concavity   of   the   elbow,    although,    when   the    catheter    is    of    a 


r 


Fig.  148. — Metal  Catheter. 
Now  rarely  u^ecl. 


large  size,  it  may  be  on  the  side,  between  the  convexity  and  the  concavity 
(Fig.  147).  Side  openings  are  generally  found  in  the  woven  catheters,  in 
which  ease  two  or  more  may  be  present.     In  the  single-elbow  catheter,  there 


CATHETERS  165 

are  rarely  more  than  two,  one  on  each  side.     Metal  catheters  are  also  better 
when  they  have  the  openings  on  the  side  (Fig.  148). 

Catheters  for  giving  a  general  irrigation  of  the  urethra  may  have  multiple 
eyes — a  dozen  or  more  small  round  openings,  through  whicli  the  water  spurts 
against  the  urethral  walls  (Fig.  149).  They  are  generally  of  soft  rubber 
in      texture.       Perineal      drainage 

catheters,   to  be   used   after  opera-      t « a « »•■  ■    « ©''■•'^ 

tion     usuallv   have    an   openino'   in       <ViiiiViViii'"^^in'iiirriumeiiiiiiriiOii(iiiYiUi^uiiuYrrioi[i\iuu\e;\Uuu^^^^ 
one    end    and    on    the    side    to    allow  Fig.  149.— Nelaton  Catheter. 

better  irrigation. 

The  Passing  of  the  Catheter. — A  soft-rubber  catheter  is  dipped  into  a  lu- 
bricant in  such  a  way  that  about  one  half  of  it  is  covered.  It  is  then  held  in 
one  hand,  with  the  fingers  a  few  inches  from  the  tip.  The  meatus  is  opened 
by  the  thumb  and  forefinger  of  the  other  hand,  the  organ  being  at  right  angles 
to  the  body.  The  end  of  the  catheter  is  then  brought  into  the  opening  while 
dangling  from  the  fingers.  After  the  tip  has  entered  the  urethral  meatus,  a 
few  downward  impulses  are  made  and  the  instrument  glides  down  the  canal. 
AVhen  the  catheter  has  passed  down  the  canal  to  the  point  at  which  the  fingers 
are  holding  it,  they  are  moved  farther  up  on  the  instrument  and  the  downward 
impulses  continued,  by  means  of  which  it  glides  through  the  deeper  portion  of 
the  canal  and  into  the  bladder.  When  eight  and  a  half  inches  of  the  catheter 
has  passed  down  the  urethra,  urine  will  usually  escape  from  its  eye.  As  the 
catheter  passes  doT\Ti  the  canal,  it  may  catch  at  the  compressor  urethrne,  or  neck 
of  the  bladder,  this  being. due  to  spasm.  Such  is  usually  the  case  when  there 
is  inflammation  of  the  prostatic  urethra,  or  of  the  neck  of  the  bladder.  Such 
a  spasm  will  usually  yield  to  gentle  pressure,  or  it  may  be  overcome  by  substi- 
tuting a  woven  for  a  soft-rubber  catheter,  or  an  olivary-tipped  instrument  for 
one  with  a  larger  end.  A  metal  catheter  will  sometimes  enter  when  others  will 
not.     Urine  will  not  escape  until  the  catheter  has  reached  the  bladder. 

Straight  catheters  are  used  for  washing  out  the  anterior  and  posterior  ure- 
thra and  bladder,  and  for  drawing  urine  from  the  bladder  that  cannot  be 
passed  spontaneously. 

Ethowed  catheters  are  also  used  in  bladder  work  in  drawing  oif  urine  in  re- 
tention and  washing  out  the  bladder  where  inflammation  is  present.  They  are 
especially  valuable  in  cases  of  enlargement  or  deformity  of  the  prostate  gland. 
The  best  coude  to  use  is  the  soft  rubber,  but  it  is  usually  not  as  easily  passed 
as  the  woven  variety. 

The  object  of  bends,  angles  or  elbows  in  the  ends  of  the  catheters  is  to  allow 
them  to  pass  over  prostatic  enlargements,  bulging  into  the  urethra.  It  is  easy 
to  understand  how  the  end  of  a  straight  catheter  would  come  up  against  a  pro- 
trusion in  the  prostatic  urethra  and  might  not  pass  it,  while  the  elbowed  catheter 
meeting  such  an  obstruction  would  have  its  convexity  at  the  end  parallel  to  the 


166  TECHNIQUE    OF    INSTRUMENTATION 

side  of  tlic  protrusion.  Its  tip  would  be  against  the  roof  of  the  prostatic  nrethra 
and  a  slight  push  would  thus  send  it  along  the  upper  wall  and  past  the  prostatic 
enlargement  into  the  bladder. 

The  metal  catheters  are  passed  the  same  as  sounds.  They  are  not  in  common 
use,  but  will  sometimes  pass  in  cases  in  which  soft-rubber  and  w^jven  instru- 
ments will  not.  At  present  I  use  the  metal  variety  almost  entirely  in  washing 
out  or  filling  the  bladder  after  a  perineal  section,  as  with  this  instrument  I  can 
hug  the  upper  wall  of  the  urethra  better,  and,  consequently,  am  not  so  liable 
to  pass  the  catheter  through  the  incision  in  the  floor  of  the  perineal  urethra  as 
might  be  the  case  with  a  straight  instrument. 

The  catheter  with  a  mandrin,  a  wire  in  its  lumen,  such  as  is  used  in  the 
urethra  to  overcome  prostatic  impediments,  is  not,  in  my  opinion,  a  good  in- 
strument. In  using  this  instrument,  it  is  passed  as  far  as  the  obstruction  in  the 
prostate  and  the  mandrin  is  then  withdrawn,  thus  giving  a  slant  to  the  tip  of  the 
catheter,  so  that  it  will  glide  up  and  forward  through  the  prostatic  urethra  and 
enter  the  bladder.  It  seems  to  me  that  the  improved  models  of  elbowed  catheters 
have  sufficiently  good  curves,  cause  less  traumatism  and  can  at  present  be  used 
in  all  cases  in  which  the  mandrin  types  were  formerly  employed. 

Retained  Catheters. — A  retained  catheter,  or  a  catheter  a  demeure,  is  one 
which,  having  been  passed  through  the  urethra,  is  fastened  in  such  a  way  that 
it  will  not  slip  out.  Retained  catheters  are  useful  whenever  it  is  desirable  to 
establish  continuous  drainage  from  the  bladder,  or  to  protect  the  walls  of  the 
urethra  from  contact  with  urine.  Usually  this  necessity  arises  when  the  blad- 
der is  infected^  when  an  operation  or  traumatism  has  been  done  in  the  urethra, 
when  it  is  necessary  to  cure  a  suprapubic  vesical  fistula,  and  also  when  sj^asms 
prevent  repeated  catheterization  in  cases  of  a  complete  retention. 

Unless  the  retained  catheter  is  properly  introduced  and  properly  main- 
tained, it  may  give  rise  to  complications,  as  an  ulceration  of  the  bladder,  Avhen 
the  instrument  is  inserted  too  far,  so  that  its  end  presses  constantly  upon  some 
point  of  the  wall.  At  other  times,  there  is  an  ulceration  of  the  upper  part  of 
the  deep  urethra,  just  beyond  the  pendulous  portion,  at  which  point  the  catheter 
is  bent  when  the  urethra  hangs  down,  thus  compressing  the  above-mentioned 
portion  of  the  wall.  These  accidents  are  rare  in  my  own  practice,  as  I  gener- 
ally use  a  soft-rubber  catheter,  and  only  employ  woven  catheters  a  demeure  im- 
mediately after  an  operation  when  there  are  blood  clots  in  the  bladder.  I 
believe  that  the  soft-rubber  catheters  made  in  this  country  are  superior  in  qual- 
ity to  the  European  jDroduct  and  that,  consequently,  we  do  not  meet  as  much 
trouble  with  retained  catheters  as  do  some  of  the  foreign  surgeons. 

Catheters  may  be  retained  for  several  days  or  several  weeks.  They  should 
be  so  introduced  that  the  eye  and  the  tip  alone  are  in  the  bladder.  This  means 
that  the  catheter  should  be  pulled  forward  lafter  having  entered  the  bladder 
until  the  flow  just  ceases  and  then  pushed  back  a  trifle  until  the  flow  is  reestab- 


CATHETEES 


167 


lisliod.     The  Lladder  is  emptied  and  the  flow  continues  in  dribbles  corresponding 
to  the  flow  of  urine  from  the  nreters. 

The  next  problem  is  to  maintain  the  catheter  in  place.     My  own  method 
is  simply  to  tie  two  pieces  of  thread  about  the  instrument  close  to  the  meatus, 


Fig.  150. — Retained  Catheter. 
P,  adhesive  plaster.  G,  gauze.  T,  retaining  threads. 

then  to  reflect  the  threads  back  on  the  upper,  lower  and  lateral  surfaces  of  the 
organ  and  to'  hold  them  in  position  by  a  piece  of  gauze  or  adhesive  plaster 
Avrapped  around  the  penis  (Fig. 
150).     The    point    at    which    tlie 


Fig.  150a. — A  More  Secure  Method  of 
Holding  a  Retained  Catheter. 

C,  catheter. 

G,  a  piece  of  gauze  surrounding  the  organ 
and  tied  to  the  instrument. 

P,  a  strip  of  plaster  passed  around  the 
gauze-covered  organ  just  behind  the  corona. 

Gl,  glans  penis. 


Fig.  151. 


Fig.  152. 


Fig.  153. 


Fig.  154. 


Fjg.  151. — Malecot's  Catheter. 

Fig.  152.— Another  Type  of  Malecot's  Catheter. 

Fig.  153. — Pezzer's  Catheter. 

Fig.  154. — Another  Type  of  Pezzer's  Catheter. 


thread  should  be  tied  around  the  catheter  is,  of  course,  determined  by  the 
maneuver  already  spoken  of,  whereby  the  exact  position  of  the  instrument  is 
secured  for  efficient  drainage.  The  catheter  can  now  be  inserted  into  the  mouth 
of  the  urinal  placed  between  the  legs. 

Special  catheters  have  also  been  devised  which  are  self-retaining  (Malecot's  or 


168 


TECHNIQUE   OF   INSTRUMENTATION 


Pezzer's,  Figs.  151,  152,  153  and  154),  Their  bladder  ends  are  wider  than  the 
rest  of  the  instrument  and  they  are  introduced  after  stretching  them  upon  a 
metallic  mandrin.  Personally,  I  never  use  these  catheters,  as  I  always  fear  that 
I  may  cause  traumatism  in  inserting  or  withdrawing  them,  especially  if  the  man- 
drin should  happen  to  slip  out  at  the  perforated  sides  and  thus  injure  the  tissues. 
They  often  enter  with  difficulty  and  pain,  and  sometimes  cause  hemorrhage. 

If  the  penis  with  the  retained  catheter  is  allowed  to  remain  too  long  in 
one  position,  it  is  said  that  periurethral  abscess  or  ulceration  followed  by  a 
fistula  may  result.     It  is  advisable,  therefore,  to  change  the  position  of  the 

penis  occasionally  by  placing  the  or- 
gan on  the  side  of  the  abdomen  and 
draining  by  siphonage  into  a  bottle  at- 
tached to  the  side  of  the  bed,  or  into 
a  urinal  in  the  bed  by  the  side  of 
the  patient.  I  often  allow  patients  to 
walk  about  with  a  urinal  between  the 
legs.      (See  Fig.  155.) 

When  it  is  unnecessary  to  have 
continuous  drainage  and  yet  it  is  con- 
sidered desirable  to  retain  the  cathe- 
ter in  the  bladder,  the  instrument  can 
be  plugged  and  the  plug  withdrawn  as 
\  If  W%\  I       often    as    necessary.      With    a    plugged 

\  ll     i  w\  /       catheter,  the  patient  is  much  more  com- 

fortable, as  he  can  move  about  in  bed  and 
in  many  cases  walk  about.  The  plugged 
catheter  may  also  be  resorted  to  in  cases 
of  complete  retention  in  which  a  large  amount  of  urine  has  accumulated  in  the 
bladder  and  is  being  gradually  withdrawn  every  two  or  three  hours.  In  certain 
spasmodic  cases,  it  may  be  desirable  to  keep  the  sphincter  stretched  until  the 
spasm  that  is  present  has  worn  off,  especially  when  the  catheter  has  been  in- 
troduced after  a  long  series  of  trials. 


Fig.  155. — Glass  Urinal  between  Legs. 


INJECTIONS 

Uretliral  injections  are  best  given  by  means  of  a  glass  syriuge  with  a 
conical  nozzle  holding;  two  drachms,  an  amount  which  usuallv  can  be  con- 
tained  in  the  anterior  nrethra.  In  making  an  injection,  the  end  of  the  glans 
should  be  held  by  the  left  forefinger  in  such  a  way  that  the  meatus  occupies 
the  middle  of  the  finger  (Fig.  156).  The  end  of  the  nozzle  of  the  syringe  is 
then  inserted  into  the  meatus ;  the  forefinger  is  now  contracted  around  the 
tip  of  the  penis,  thus  pressing  the  end  of  the  urethra  containing  the  syringe 


IRRIGATIONS 


169 


tip  so  firmly  against  it  that  the  injection  does  not  leak  around  the  sides  of 
the  syringe  and  is  contained  in  the  urethra  (Fig.  157).  As  the  syringe  tip  is 
withdrawn  from  the  meatus,  the 
forefinger  maintains  its  pressure 
on  the  end  of  the  urethra,  thus 
keeping  the  solution  in  the  canal 
as  long  as  desired  (Fig.  158). 
Injections  are  usually  retained 
for  five  minutes  and  are  then  al- 
lowed to  escape. 


Fig.  156. — Relative  Position  of  Meatus  and  Nozzle; 
OF  THE  Syringe. 


Fig.  157. — Manner  of  Holding  the  Nozzle  of  the     Fig.  158. — How  the  Solution  is  Held  in 
Syringe  in  the  Urethra.  the  Urethra. 

The  meatus  is  seen  in  the  bend  of  forefinger. 

IRRIGATIONS 

These  include  irrigations  of  the  antero-posterior  urethra  and  bladder  or  of 
the  anterior  urethra  alone. 

(a)  With  the  Piston  Syringe  Alone. — The  syringe  is  held  in  the  right  hand 
of  the  surgeon,  while  the  meatus  is  compressed  by  the  forefinger  of  the  left 


170 


TECHNIQUE    OF   INSTRUMENTATION 


hand.      The  piston   is   pressed  upon    until   the   nrethra   is   filled   and   inflated. 


The   fluid   can   then   either  he   lidd 
then   tilled   aiiain.      'J'lie   fluid   mav 


Fig.  159.  —  A  Laege  Piston  Syringe  (Bladder  Steinge) 
Used  for  Urethro- vesical  Irrigations  and  Washing 
OUT  THE  Bladder  through  a  Catheter. 


ill  or  allowed  to  escape,  and  the  canal 
he  introduced  into  the  posterior  nrethra 
and  hladder  hy  gradually 
increasing  the  pressure  on 
the  piston,  thus  overcoming 
the  compressor  urethme  and 
the  vesical  sphincter  mus- 
cles. I  am  not  in  favor  of 
this  procedure  and  never 
use  it. 

(&)  With  a  Piston  Syringe  and  Catheter. — If  this  is  simply  for  the  pur- 
pose of  washing  out  the  anterior  nrethra,  the  catheter  is  passed  down  to  the 
bulb  and  the  tip  of  the  syringe  is  introduced  into  the  end  of  the  catheter.  The 
solution  is  injected  slowly  and  is  allowed  to  escape  along  the  side  of  the  catheter. 
If  the  catheter  is  now  pushed  into  the  membranous  portion,  the  fluid  will  still 
escape  from  the  urethra,  or  will  flow  both  into  the  anterior  and  posterior  urethra. 
If  the  end  is  pushed  into  the  prostatic  portion  of  the  canal,  the  membranous 
sphincter  will  prevent  the  fluid  from  escaping  and  after  filling  the  prostatic 
urethra,  the  solution  will  pass  into  the  bladder.  The  catheter,  however,  is  com- 
monly used  in  filling 
and  washing  out  the 
bladder,  in  which  case 
it  is  at  once  passed 
into  the  bladder  and 
the  organ  is  filled  by 
the  piston  syringe. 
The  fiuid  can  then 
either  escape  through 
the  catheter  after  the 
syringe  is  removed,  or 
the  catheter  is  with- 
drawn and  the  patient 
allowed  to  void  the 
contents  of  the  blad- 
der, thus  medicating 
the  urethra. 

(c)  With  an  Irri- 
gator   Working    by 
Hydrostatic    Pressure 
without  a  Catheter. — The  irrigation  of  the  urethra  without  a  catheter  by  hydro- 
static pressure  is  very  effective  in  treating  urethral  inflammation.     For  this 


Fig.  160.  —  Cut-off,  Nozzle  and  Shield  with  a  Tube  Passing  to 
A  Douche  Jar,  for  Giving  Urethral  and  Urethro-vesical  Ir- 
rigations BY  Hydrostatic  Pressure. 


IKEIGATIONS 


171 


method  it  is  necessary  to  have  a  reservoir  containing  the  solution  to  be  used. 
With  this  is  connected  a  piece  of  rubber  tubing  to  which  is  attached  a  nozzle,  the 
tip  of  which  is  inserted  into  the  meatus.  The  reservoir  is  then  raised  to  a  suf- 
ficient height  to  force  the  fluid  to  run  into  the  urethra  and  as  far  as  the  back  of 
the  bulb.  Pressure  is  then  made  on  the  tip  of  the  penis,  thus  pressing  the  meatus 
against  the  nozzle.  The  fluid  then  passes  into  the  urethra  as  far  as  the  com- 
pressor urethra  muscle  and  escapes  when  pressure  is  removed. 

The  Janet  Method. — In  case  it  is  necessary  to  introduce  the  fluid  into  the 
prostatic  urethra  and  the  bladder,  the  reservoir  is  raised  so  that  its  lowest  part 
is  about  a  yard  and  a  half  above  the  pubes.     The  pressure  on  the  meatus  is 


FiQ.  161. — Author's  Method  of  Suspending  Douche  Jars  for  Irrigations  in  Office, 

Hospital  and  Clinic. 


maintained  and  the  patient  is  instructed  to  breathe  deeply  and  try  to  relax  all 
the  muscles^  or  else  to  try  to  pass  out  the  fluid  that  is  in  the  canal.  The  effort 
to  urinate  relaxes  the  cut-off  muscle  and  allows  the  solution  to  enter  the  bladder, 
after  which  the  patient  passes  it  out. 

The  douche  jars  vary  in  shape,  but  are  usually  conical.  They  are  made  of 
glass  with  a  metal  collar  about  the  neck,  to  which  is  attached  a  metal  bucket 
handle.     This  handle  can  be  used  to  suspend  the  jar  from  a  hook,  or  a  cord  can 


172 


TECHNIQUE    OF   INSTRUMENTATION 


be  attached  to  it  that  is  passed  through  a  pulley  by  means  of  which  it  can  be 
raised  or  lowered  as  desired.  Other  reservoirs  arc  flat  on  one  side  and  these 
fit  better  to  the  wall.  Some  of  the  jars  are  graduated.  Rnl)l)er  fountain 
syringes  are  used,  but  are  not  so  easily  sterilized  and  do  not  allow  one  to  see 
the  level  of  the  fluid. 

Various  ways  of  suspending  these  jars  have  been  tried  by  us  in  office  and 
clinic  practice.     They  are  illustrated  in  Fig.  161. 

A  represents  a  board  nailed  to  the  wall,  the  door  or  a  window  frame.  B 
is  a  hook  to  which  is  hung  a  pulley.  C  is  the  irrigator.  D  is,  a  piece  of  cord, 
one  end  of  which  is  attached  to  the  handle  of  the  irrigator.  The  other  end  runs 
through  the  pulley  and  is  fastened  to  a  cleat,  E,  on  the  wall. 


E 


UvT* 


Fig.  162. — Author's  Apparatus  for  Irrigating  Urethra  and  Bladder  by  Hydrostatic  Pressure. 


P  shows  a  gas  j^ipe  stretching  across  the  ceiling  of  the  room  to  which  a  pul- 
ley is  attached  at  B  by  means  of  a  wire.  The  cord  runs  from  the  irrigator 
handle  through  this  pulley  to  the  cleat,  as  has  just  been  described.  This  second 
method  has  many  advantages,  inasmuch  as  a  series  of  irrigators  can  be  strung 
from  one  pijDe. 

F  shows  an  upright  fastened  to  the  table  which  supjiorts  an  irrigator.  G 
shows  a  fountain  syringe  hung  on  a  nail  on  the  wall. 


IRRIGATIONS  I73 

The  object  of  tlie  pulleys  is  to  regulate  the  pressure  of  the  fluid  l)y  raising 
or  lowering  the  reservoir.  If  the  jars  are  stationary,  the  force  of  the  stream 
can  be  regulated  hy  means  of  the  cut-off  to  be  described  l)elow. 

The  irrigator  is  connected  by  moans  of  a  rubber  tube  about  three  yards  long 
with  cut-off,  shield  and  nozzle.  The  first  figure  (Fig.  1C2)  shows  (/I)  the  rub- 
ber tube  leading  from  the  irrigator;  (B)  the  hard-rubber  coupling  in  which  the 
nozzles  (D)  fit,  and  which  is  pi'ovided  with  a  cut-off  valve  at  C.  This  valve  can 
he  so  regulated  by  pushing  upon  its  lever  that  one  can  either  shut  off  the  solu- 
tion or  allow  it  to  flow  at  different  velocities.  Over  the  body  of  the  coupling, 
fits  shield  E,  which  is  a  cup-shaped  guard  intended  to  prevent  the  water  from 
splashing  or  spilling.  Into  the  coupling,  B,  fit  the  various  nozzles  provided  for 
the  apparatus,  D-1,  D-2,  D-3  and  DA.  D-1  has  a  blunt  end  suitable  for  irrigat- 
ing the  urethra  by  hj'drostatic  pressure.  D-2  is  elongated  into  a  tip  that  can 
easily  be  inserted  into  a  catheter.  D-3  is  a  short  nozzle,  with  an  olivary  tip, 
made  for  irrigating  the  fossa  navicularis  and  D-4:  is  the  same  shape  but  long 
enough  to  extend  to  the  bulb,  for  irrigating  the  bulbous  portion  of  the  urethra. 
It  has  also  an  olivary  tip. 

The  shield,  which  is  pictured  in  the  figure  (E),  is  the  one  I  prefer  in 
my  own  w^ork,  A  number  of  shapes  have  been  tried  at  my  clinic  at  the  Post- 
graduate Hospital.  At  first  we  irrigated  without  any  shield,  using  simply  hard- 
ruliber  nozzles  at  the  end  of  the  rubber  tubing.  We  next  tried  round,  soft-rub- 
ber shields  with  an  opening  through  which  the  nozzle  could  be  pushed. 
I  have  for  many  years  used  the  copper  detachable  hemispherical  shield,  modeled 
after  half  of  a  hollow  rubber  ball,  which  I  have  found  to  be  most  satisfactory. 


Fig.   163. — Irrigating  Kollmann  Dilator. 

(cl)  With  Irrigating"  Dilators. — Irrigating  dilators  are  used  for  the  purpose 
of  irrigating  the  canal  when  it  is  dilated.  They  are  of  the  Kollmann  pattern, 
the  dilating  portion  of  which  is  composed  of  four  blades.  They  can  be  used 
without  sheaths  or  covers,  such  as  are  placed  upon  other  dilators.  They  are 
straight  or  curved  with  a  Benique  curve.  They  are  introduced  into  the  urethra, 
their  blades  are  separated  by  turning  the  wheel  in  the  handle  of  the  instrument. 
This  smooths  out  the  mucous  membrane  and  opens  the  mouths  of  its  follicles. 
The  attachment  is  then  made  and  the  solution  is  allowed  to  run  through,  which 
thoroughly  washes  the  urethra,  while  it  enters  the  ducts,  emptying  into  the  canal 
as  much  as  possible. 


174 


TECHNIQUE   OF   INSTRUMENTATION 


INSTILLATIONS 

Instillation  is  the  injection  of  a  solution  by  drops  into  the  urethra  or  blad- 
der. This  is  done  either  with  or  without  a  catheter.  The  object  of  an  instilla- 
tion is  to  apply  a  strong  solution  to  a  definitely  circumscribed  portion  of  the 


Pig.  165. 


Fig.  164. — Guyon's  Instillating  Syringe. 

canal  and  allow  it  to  remain  there,  in  contra- 
distinction to  an  injection,  which  acts  upon  the 
entire  anterior  urethra  and  is  allowed  to  escape 
after  holding  it  for  a  few  minutes. 

The  Guyon  instrument  (Fig.  164)  is  a 
piston  syringe,  the  barrel  of  which  is  gradu- 
ated  and   which   holds   4   grams    (1    drachm). 

The  tip  of  the  syringe 
is  attached  either  to 
an  olive-ended,  hollow 
bougie  or  to  a  catheter 
Avith  a  perforation  at 
the  extremity. 

The  Ultzman  in- 
strument is  a  piston 
syringe  holding  twen- 
ty drops  attached  to  a 
curved,  hollow  sound 
(Fig.  166). 

The  solution  used 
in  instillations  consists 
of  silver  nitrate,  in  the 
strength    of   from    one 


-Manner   of   Giving  an  Instillation   of  the   Urethra 
WITH  the  Guyon  Instillator. 

to  five  per  cent  for 
the  stronger  effects  or  of  1 :  500  or  1 :  2.50  for  milder  action.  Exceptionally, 
a  caustic  effect  is  obtained  by  the  use  of  ten-per-cent  solutions  of  silver  nitrate. 
The  amount  of  the  latter  is  limited  to  three  or  four  drops,  while  the  weaker 
solutions  are  injected  in  quantities  of  from  five  to  thirty  drops.  Other  silver 
salts  are  used  and  will  be  considered  in  the  chapter  on  Urethritis.  Some  sur- 
geons use  strong  solutions  of  bichlorid  of  mercury  and  sulphate  of  copper  for 
instillations,  but  I  do  not  recommend  them. 


INSTILLATIONS 


175 


Instillations  can  either  be  given  in  the  anterior  or  the  posterior  urethra. 
The  method  of  procedure  is  as  follows :  The  patient  is  allowed  to  pass  his 
urine  and  the  external  parts  are  cleaned  in  the  nsnal  manner.  For  instil- 
lations in  tlie  anterior  urethra  Giiyon's  perforated,  olive-tipped  catheter  is 
used  and  is  introduced  as  far  as  the  point  of  localized  inflammation  (Fig. 
1()5).  The  tip  of  the  piston  syringe  is  then  introduced  into  the  outer  end 
of  the  catheter  and  the  fluid  is  slowly  injected,  from  ten  to  fifteen  drops  being 
used. 

In  instillation  of  the  posterior  urethra,  as  practiced  with  the  aid  of 
the  Guyon  apparatus,   the  end  of  the  catheter   is   passed  into  the  posterior 

urethra  and  the  solution  deposited  there  in  the  same 


way. 


J 


Fig.  166. — Ultzman's  Instillating  Syringe. 

The  Ultzman  syringe  is,  however,  generally 
used  for  the  posterior  urethra.  The  hollow  sound 
and  the  piston  syringe  are  connected  and  the  syringe 
filled    with    the    solution.      It    is    then    passed    into 

the  posterior  urethra 
like  a  sound  and  the 
solution  instilled  into 
it^ — ^usuall'y  ten  to 
twenty  drops.  If  the 
tip  has  reached  the 
bladder,  by  rotating 
the  instrument  it  can 
be  felt  to  move  freely 
about  and  it  should 
then  be  withdrawn 
until  it  rests  in  the 
comparatively  narrow 
confines  of  the  pros- 
tatic urethra.  In  giv- 
ing bladder  instilla- 
tions, either  apparatus  can  be  used,  the  end  of  the  instrument  being  introduced 
into  the  urethra  and  the  entire  amount  contained  in  the  syringe  instilled.  Usu- 
ally from  thirty  to  sixty  drops  are  instilled  and  left  to  act  locally  (Fig. 
167). 


Fig.  167. — Manner  of  Injecting  the  Posterior  Urethra  by  Means 
OF  the  Ultzman  Instillator. 


17G 


TECI-miQUE    OF    INSTRUMENTATION 


SOUNDS 

A  sound  is  a  metal  instrnment  coiisistinii^  of  a  shaft  and  a  handle.     The  shaft 
is  round,  8]  to  10  inelies  lonij',  jnid  tajicrs  toward  its  distal  end,  which  is  curved 


Fig.  168. — Cubves  of  Sounds  Recommended  are  A,  B,  E,  Van  Buren;  C,  B,  D,  Bknique; 

F,  B,  E,  Otis. 

and  well  rounded  at  its  tip.  The  handle  is  a  piece  of  flattened  metal,  abont  2^ 
inches  long,  wider  in  its  transverse  diameter  and  not  so  thick  as  the  remainder 
of  the  instrument.     The  cnrve  of  the  sound  varies  in  its  lenoth  and  deeree. 


G  .TIEMANN-  CO.  NY. 


OOOOOo  oooo 


5       4.       4      3 


Fig.   169. — French  (Charri^re)  Sound  Scale,  Compared  with  English  Measurement. 

There  is  the  long  cnrve,  the  short,  the  acnte  and  the  less  marked.     Straight 
sounds  are  also  made,  but  are  very  rarely  used. 


SOUNDS 


177 


The  sounds  principally  nscd  in  this  conntry  arc  the  Van  Bnren,  the 
Bonique  and  the  Otis.  The  following  diagTams  illustrate  these  curves  and 
arguments  have  been  made  in  favor  of  each  (Fig.  168).  The  short  cnrve  FBE 
is  the  one  tliat  I  generally  nso  in  my  urethral  work,  although,  fen*  the  dilatation 
of  hard  strictures  difficult  of  dilation,  CBD  is  preferable,  not  on  account  of 
its  shape,  but  because  the  difference  between  the  sizes  of  the  Benique  sounds 
is  only  half  what  it  is  between  the  sizes  of  the  other  sounds  of  the  ordinary 
Freuch  scale,  the  Charricre  (Fig.  169).  I  also  prefer  the  short  curve 
liecause  I  believe  that  I  can  pass  it 
uiore  easily  and  feel  the  urethra 
better  than  I  can  with  any  other 
sound  (Fig.  170). 

Technique  of  Passing  Sounds. — This  depends  on  the  teaching  in  different 
countries  and  in  different  schools.  In  this  country,  the  physicians  pass  sounds 
from  the  left  side  of  the  patient,  whereas  in  Europe,  they  are  passed  from  his 
right.      The  patient  is  placed   in   a   reclining  position,   his   body  making   an 


Fig.  170. — Sound  Curve  Preferred  by  Author. 


^Sfcv. 


Fig.  171. — First  Step  of  Passing  a  Sound. 

angle  of  about  22|-°  with  the  table.  (1)  The  physician  stands  on  the  left  side 
of  the  patient  and  grasps  the  handle  of  the  sound  between  the  thumb  and  fore- 
finger of  the  right  hand,  while  he  grasps  the  penis  with  the  left  hand  and  holds 
it  perpendicular  to  the  body.  lie  passes  the  sound  over  the  thigh  at  right 
angles  to  its  side  and  inserts  its  tip  into  the  urethra  (Fig.  ITH.  (-)  If  the 
sound  is  of  the  proper  size  and  is  not  held  back  by  the  operator,  it  should  slide 


178 


TECHNIQUE    or   IXSTRTTMENTATION 


down  the  urethra  by  its  own  weight  as  far  as  the  bulb.     The  handle  is  then  some- 
what elevated  and  when  the  instrument  ceases  to  glide,  it  shonld  be  swung 


Fig.  172. — Second  Step  of  Passing  a  Sound. 


Fig.   173. — Thikd  c^tep  of  P.\ssing  a  tiouxD. 


SOUNDS 


179 


aroimd  gently  toward  the  pnl)os  until  it  is  over  tlie  symphysis  and  the  median 
line  of  the  body,  correspond ing-  to  the  linea  alba  (Fig.  172).  (3)  The  organ 
is  then  extended  and  steadied  by  the  fingers  of  the  left  hand,  while  the  right 


Fig.   174. — Benique  Sound,   With  and  Without  Filiform  Guide. 

Iiand  gently  moves  the  sonnd  in  the  arc  of  a  circle  from  the  abdomen  to  be- 
tween the  thighs    (Fig.    173).      In  passing  the  sound,   the  right   hand  simply 


Fig.   175. — First  Step  of  P.\ssing  a  Benique  Sound. 

guides  the  sound,  while  the  left  hand  keeps  the  organ  fairly  well  on  the  stretch, 

so  that  the  tip  of  the  instrument,  in  passing  the  perineal  part  of  the  urethra, 

will  hug  the  middle  line  of  the  roof  of  the  canal  and  not  catch  along  its  course. 

If  the  meatus  is  tight,  the  physician  should  pull  the  glans  penis  up  toward 


180 


TECHNIQUE    OF    IXSTRUMEXTATIOX 


the  handle  of  the  sound  from  time  to  time,  Avliicli  \\\]\  allow  the  part  of  the 
sound  heyond  the  meatus  to  glide  down  farther  into  the  canal.  In  this  way,  tlie 
hugging-  of  the  sound  by  the  meatus  can  be  overcome.  A  meatus  smaller  than 
the  remainder  of  the  canal  should  be  cut. 

In  case  the  end  of  the  sound  catches  in  the  perineal  urethra  and  does  not 
pass  through  its  curve,  this  can  often  be  aided  by  taking  the  instrument  in  the 
left  hand  and  simply  pressing  over  the  pubes  and  suspensory  ligament  with  tbo 
palmar  surface  of  the  fingers  of  the  right. hand.     If  tliis  does  not  suffice,  the  fin- 


FiG.  176. — Second  Step  of  Passing  a  Benique  Sound. 


gers  of  the  left  hand  can  be  placed  in  the  perineum  to  steady  and  lift  the  end  of 
the  sound  out  of  any  pocket  that  it  may  happen  to  be  in,  up  against  the  anterior 
wall  of  the  urethra  and  in  contact  with  the  ojiening  of  the  meudjranous  uretlira. 

In  France,  the  Benique  sound,  which  has  a  long  and  jironounced  curve  like 
that  of  the  perineal  uretlira,  is  principally  used.  These  instruments  are  well 
adapted  for  stretching  strictures,  because  they  increase  in  size  more  gi'adually, 
by  one  sixth  of  a  millimeter,  instead  of  one  third  of  a  millimeter.  They  are  used 
with  a  guide  like  a  filiform  bougie,  fixed  into  a  metal  socket  with  a  screw  at  the 
end  (Fig.  174),  wdiich  is  screwed  into  a  corresponding  opening  in  the  end  of  the 
sound  (Fig.  174).  The  guide  is  passed  through  the  urethra  into  the  bladder, 
and  the  sound  screwed  on,  after  which  tlie  instrument  is  also  introduced. 

The  French  method  of  passing  metal  sounds  is  as  follows: 


SOUNDS 


181 


(1)  Tlic  oporator  stanrls  on  the  right  side  of  the  patient,  holding  the  penis 
\vith  his  left  hand  and  the  s(»und  with  his  right,  so  that  its  concavity  points  to 


Fig.  177. — Thihd  Step  of  Passing  a  Benique  Sound. 

the  right  tliigh   (Fig.   175).     He  guides  it  down  the  urethra  to  the  perineal 
portion,  at  the  same  time  drawing  the  organ  over  the  instrument  around  toward 


Fig.  178. — Fourth  Step  of  Passing  a  Benique  Sound. 


182 


TECHNIQUE    OF    INSTRUMENTATION 


the  median  line  (Fig.  170).  (2)  The  left  hand  then  draws  the  organ  up  in 
front  of  the  abdomen  (Fig.  177).  (3)  When  the  end  of  the  sound  engages  in 
the  membranous  portion,  the  left  hand  drops  the  organ  and  presses  supra- 
liubieally  over  its  suspensory  ligament,  while  the  right  haud  guides  tlie  instru- 
ment into  the  bladder  (Fig.  178). 


DILATORS 

Urethral  dilators  are  instruments  shaped  like  sounds  that  can  be  enlarged 
by  turning  a  wheel  at  the  distal  end,  so  as  to  stretch  different  portions  of  the 

canal.  The  shaft  of  the  in- 
strument, where  the  dilata- 
tion takes  place,  is  com- 
posed of  blades,  bands  of 
steel,  that  separate  from 
one  another  either  antero- 
posteriorly,  or  both  antero- 
posterior ly  and  laterally, 
when  the  wheel  is  turned. 
A  dial  near  the  Avheel  regis- 
ters the  amount  of  dilata- 
tion. 

The  instruments  in 
Avhich  the  bands  separate 
antero-posteriorly  are  called 
the  Oberlander,  and  the 
others  in  which  they  sepa- 
rate both  antero-posteriorly 
and  laterally,  are  called  the 
Kollmann  dilators. 

The  Oberlander  dilator 
is  of  three  forms,  two  with 
a  flat  curve  for  the  anterior 
urethra  (Fig.  170,  Xos.  1 
and  2),  another  with  a  curve 
like  a  sound  for  the  antero- 
jiosterior  urethra  (No.  3) 
and  the  third  with  a  more  pronounced  curve,  Benique,  for  the  posterior  portion 
of  the  canal  (!N"o.  4). 

Of  these  four  Oberlander  dilators,  Xo.  3  is  the  best,  as  it  can  be  used  for 
the  deep  anterior  urethra  and  the  membranous  and  posterior  portions  by  intro- 
ducing it  until  the  beak  is  in  the  bladder  and  then  dilating.     Or  it  can  be  used 


No.  1. 


No.  3.  No.  4. 

-Oberlander  Dilators. 


DILATORS 


183 


simply  for  tlio  dilatation  of  the  anterior  urethra,  hy  inserting  it  and  dilating 
when  the  instrument  is  at  right  angles  to  the  table.  All  these  instruments,  when 
they  are  closed,  show  no  space  between  the  two  blades  of  the  dilator. 


No.  5. 


No.  6. 


6. 

7. 
8. 
9. 

10. 

11. 

12. 


No.  7.  No.  8.  No.  9.  No.  10.  No.  11. 

Fig.   ISO. — Kollmann's  Dilators. 

Kollmann's  straight  articulated  4-bladed  dilator  for  the  anterior  part  of  the  urethra,   with  short 

branches. 
"  "  "  "  11         11      i<    anterior  parts   of   the   urethra,    with  long 

branches. 
"  "         "      "    posterior  part  of  the  urethra. 

"  "         "      "  "         and  part  of  the  anterior  urethra. 

"  "         "      "  "         part  of  the  urethra,  with  Guyon's 

curve. 
"  "        "      "  "         and  part  of  the  anterior  urethra, 

with  Guyon's  curve. 
"  "         "      "    anterior  part  of  the  urethra,  with  irrigating 

attachment. 
"  "        "      "    posterior  and  part  of  the  anterior  urethra, 

with    irrigating     attachment.       (Shown 
in  Fig.  184.) 


curved 

double-curved 
straight 
curved 


The  dilator  of  Oberliinder  (Fig.  179,  ISTo.  3)  is  composed  of  a  shaft;  of  two 
pieces  of  steel,  with  three  small  levers  between  them;  a  handlepiece,  composed 
of  the  body  where  the  two  pieces  of  steel  come  together ;  a  screw  connected  with 
the  wheel,  at  the  end  of  the  handle  for  separating  the  two  pieces,  of  which  the 


184 


TECHNIQUE    OF   INSTKUMENTATION 


instruiiunit  is  composed;  a  metal  looj)  for  holding-  the  instrument  and  a  dial, 
which  records  the  number  of  millimeters  of  dilatation.  When  the  Oberliinder 
is  inserted,  it  is  of  the  size  No.  16  French,  and  when  fully  opened,  Xo.  40 
French. 

The  Ivollmann  dilators  (Fig,  180)  are  worked  on  the  same  principle  as  the 
Oberliinder,  but,  as  tliej  have  four  blades,  they  dilate  on  four  sides  and  thus 
make  more  even  distention.  They  dilate  from  24  to  50  French.  The  posterior 
dilator,  like  the  posterior  Oberlander,  has  the  Benique  curve. 

The  blades  of  the  Kollmann  dilators  are  arranged  in  such  a  way  that  two 
blades  lie  at  right  angles  to  the  other  two,  so  that  the  cross  section  of  the  instru- 
ment at  its  widest  point  is  shaped  like  a  cross  (Fig.  181). 


i 


Fig.  181. — Blades  of  a  Kollmann  Dilator. 
A,  cross  section  of  blades  closed.  B,  cross  section  of  blades  open. 

These  four-bladed  dilators  of  Kollmann  are  made  in  three  different  types: 
Two  straight  Kollmann  dilators,  which  are  used  only  in  the  anterior  urethra 
(Fig.  180,  ISTos.  5  and  6),  two  curved  posterior  dilators,  which  are  used  for 
the  posterior  urethra,  as  the  blades  separate  only  at  the  distal  end  (Fig. 
180,  ISTos.  7  and  9)  and  finally,  the  dilators  which  dilate  both  the  anterior  and 
posterior  parts  of  the  canal  (Xos.  8  and  10). 

Of  the  Kollmann  dilators  without  an  irrigating  attachment,  if  but  one  is 
to  be  used,  the  instrument  with  the  curve  like  a  sound  for  dilating  both  the  an- 
terior and  posterior  part  of  the  urethra,  No,  8,  is  the  most  useful. 

The  posterior  Kollmann,  No,  9,  is  also  of  great  value,  as  in  many  cases 
of  chronic  prostatitis  it  is  necessary  to  dilate  the  posterior  urethra,  and,  as  it  is 
so  much  larger  than  the  remainder  of  the  canal,  the  necessary  dilatation  would 
not  be  obtained  by  means  of  an  antero-posterior  dilatation  without  danger  of 
rupturing  the  anterior  or  membranous  portion. 

The  varieties  of  instruments  just  described,  both  Oberlander  and  Kollmann, 
are  all  used  with  a  rubber  cover  or  sheath  to  prevent  their  blades  from  pinch- 


DILATORS 


185 


ino-  (lie,  urt'lliriil  mucous  membrane  wlien  closing  them  and  thus  causing  trau- 
malism  (Figs.  1S2,  183).  The  Obcrlanfler  with  a  curve  like  a  sound  (No.  3) 
is  the  best  of  the  Oberliinder  group,  while  the  antero-j)Osterior  Kollmann  (No. 


Fig.  182 


Figs.  182  and  183. 


Fig.  183. 
-Rubber  Sheaths  Drawn  Over  the  Dilators. 


8)  is  the  best  of  this  group.  Kollmann  dilators  are  better  than  the  Oberlander. 
The  posterior  Kollmann  (No.  9)  is  the  best  instrument  for  stretching  the  pros- 
tatic portion  of  the  urethra  alone. 

There  are  two  other  varieties  of  Kollmann  dilators — one  straight  irrigating 
instrument  (Fig.  180,  No.  11),  and  another  curved  dilating  instrument  with 
an  irrigating  attachment  (Fig.  184).  These  two  instruments  are  naturally 
nuide  to  use  without  a  cover  and  do  not  pinch  the  mucous  membrane  of  the 


Fig.  184. — Kollmann  Irrigating  Dilator. 

urethra,  as  when  they  are  closed  the  blades  touch  only  at  their  inner  angle.  The 
irrigating  Kollmann  has,  in  addition  to  the  ordinary  dilating  instrument,  a 
hollow  shaft  for  irrigating  purposes,  and  a  bell  or  guard  to  catch  the  irrigating 
fluid  as  it  escapes  from  the  urethra. 

Technique  of  Instrumentation. — The  cover  is  drawn  over  the  dilator.  The 
instrument  is  then  dipped  into  glycerin  or  some  other  sterile  lubricant  that 
mixes  with  water,  such  as  lubrichondrin,  and  is  passed  into  the  urethra  the  same 
as  a  sound.  The  straight  instrument  is  only  passed  into  the  anterior  urethra 
until  it  is  in  a  position  perpendicular  to  the  table  (that  is,  at  an  angle  of  90°), 
when  the  dilatation  is  made. 

The  antero-posterior  and  the  posterior  Kollmann  are  passed  into  the  bladder 


186  TECHNIQUE    OF   INSTKUMENTATION 

in  the  same  manner  as  a  sound  and  are  allowed  to  remain  in  the  position  that 
they  naturally  assume,  which  is  at  an  angle  of  about  45°  with  the  table.  The 
dilatation  is  made  in  this  position. 

The  dilator  is  steadied  by  its  handle  with  the  fingers  of  the  left  hand, 
while  those  of  the  right  hand  grasp  the  wheel  controlling  tlie  distention  of 
the  blades,  and  slowly  turn  it  to  the  right  until  the  degree  of  dilatation  desired 
is  indicated  on  the  dial.  But  it  must  be  remembered  that  if  the  patient 
complains  of  pain,  or  if  any  undue  resistance  is  felt,  the  dilatation  should  not 
be  pushed  any  farther.  The  dilator  is  left  in  place  for  a  few  minutes.  It  is 
then  closed  by  turning  the  wheel  in  the  reverse  direction,  after  which  it  is  gently 
withdrawn. 

When  the  urethra  is  narrowed  by  a  stricture,  the  ISTo.  16  French  Oberlandcr 
may  be  the  only  dilator  that  will  pass  it,  and  the  first  dilatation,  therefore,  will 
be  up  to  'No.  17  French.  The  average  dilatation  at  the  first  treatment  with  the 
Kollmann  dilator  can  be  said  to  be  about  ISTo.  25  French. 

The  rule  is  to  increase  at  subsequent  treatments  by  one  or  two  numbers  of 
the  French  scale  each  time.  It  must  be  remembered  also  that  the  two-bladed 
dilator  of  Oberlander  causes  more  tension  than  the  four-bladed  one  of  Koll- 
mann, and  that,  consequently  lower  degrees  of  dilatation  must  be  begun  with  it. 
After  a  size  of  No.  32  or  35  French  has  been  reached,  the  dilatation  should  be 
increased  very  slowly,  indeed,  a  fraction  of  a  degree  at  a  time. 

The  duration  of  the  dilatation  at  each  treatment  should  be  about  ten  min- 
utes up  to  No.  32  French;  about  fifteen  minutes  from  ]S[o.  32  to  36  French, 
and  even  longer  with  higher  degrees  of  dilatation. 

After  dilating  the  urethra  by  means  of  dilators,  the  canal  should  be  irri 
gated  with  some  antiseptic  solution,  unless  the  irrigating  Kollmann  is  used. 

In  using  the  irrigating  Kollmann  dilator  (Fig.  184),  it  is  passed  in  the  same 
way  as  the  other  dilators  until  its  curve  corresponds  Avith  that  of  the  urethra. 
The  outflow  tubing  from  the  reservoir  or  douche  bag  is  then  connected  with 
the  nozzle  on  the  handle  portion  of  the  instrument,  and  the  solution  runs 
through  a  central  hollow  shaft  and  escapes  from  slits  in  its  sides,  thus  irrigat- 
ing the  urethra  and  running  out  along  the  sides  of  the  instrument  against  the 
bell  and  then  into  a  receptacle,  such  as  a  douche  pan,  placed  beneath  the  patient's 
buttocks,  or  some  other  pan  placed  between  the  legs.  It  is  a  most  satisfactory 
instrument. 

The  irrigating  Kollmann  dilator  is  of  a  rather  complicated  construction.  It 
can  be  boiled,  or  at  least  its  lower  portions  can  be,  and  the  mechanism  at  the 
handle  is  ojoen  so  that  it  can  be  frequently  cleaned  and  oiled. 

The  care  of  dilators  is  important,  as  the  surgeon  will  find  that,  unless  they 
are  well  cared  for,  they  rust  and  get  out  of  order.  They  should  always  be 
opened  to  their  fullest  extent  after  using,  should  be  thoroughly  cleansed  and 
dried,  especially  at  the  joints  and  cross  pieces,  and  should  be  ^Tiped  with  a  very 


DILATOKS  187 

thin  coat  of  vaselin  and  kept  free  from  dust.  Some  prefer  to  clean  tlie  dilators, 
after  they  liave  been  nscd,  with  liquid  soap,  and  to  wipe  them  with  alcohol. 
The  covers  should  be  kept  in  a  cool  j)lace,  free  from  moisture  and  covered  with 
talcum.  Talcum  can  also  be  dusted  into  the  covers  before  applying  them  to  the 
dilators,  but  this  is  not  a  good  plan,  inasmuch  as  the  powder  clogs  the  joints. 
The  dilators  with  their  covers  can  be  sterilized  in  a  formalin  sterilizer.  With 
care  a  cover  lasts  about  a  dozen  treatments. 


I 


I 


CHAPTER    IX 


URETHROSCOPY 


The  visual  examination  of  the  urethra  through  a  metal  tube  by  means  of  an 
artificial  light  reflected  into  it,  or  by  means  of  a  lamp  in  the  distal  part  of 
the  tube  near  its  end,  has  been  one  of  the  greatest  advances  in  modern  urology. 

Desormeux,  in  1S53,  was  the  first  to  devise  a  urethroscope  of  any  value. 
He  used  a  tube  illuminated  by  a  lamp,  the  rays  from  which  were  thrown  into 
the  urethra  by  means  of  mirrors.  Various  other  modifications  were  then  made, 
using  reflected  light,  until  ISTitze,  in  1878,  constructed  an  instrument  which 
later  became  known  as  the  ISTitze-Oberlander,  in  which  the  urethral  field  was 
illuminated  by  means  of  a  lamp  in  the  tube.  Since  then,  many  modifications 
have,  been  brought  out,  such  as  the  Antal,  Casper,  Chetwood,  Fenwick,  Gorel, 
Klotz,  Mark,  Otis,  Powell  and  Valentine,  the  most  practical  of  which  were 
those  that  had  the  lamp  in  the  tube. 

Urethroscopy  was  revolutionized  and  made  simple  by  the  introduction  of 
the  Mignon  lamp  by  Drs.  Koch  and  Preston  of  Rochester.  This  lamp  was  prac- 
tically cold  and  was  inserted  into  the  tube  on  a  carrier.  Chetwood,  Valentine 
and  myself  were  among  the  first  to  use  this  variety  of  illumination  in  the  ure- 
throscope. 

The  urethroscope  which  bears  my  name  consists  of  a  tube  six  inches  long 
and  rounded  at  the  distal  end ;  but  the  remaining  part  of  the  tube,  extending 


Fig.  185. — Guiteras  Urethroscope. 


from  this  point  to  the  disk  at  its  proximal  end,  has  its  lower  arc  transformed 
into  a  gutter  which  is  not  separated  from  the  remainder  of  the  tube. 

The  illuminating  apparatus  consists  of  a  thin  rod  or  wire  carrier,  at  the 

188 


URETHROSCOPY 


189 


distal  end  of  wliicli  is  the  Mignon  lamp.  At  the  proximal  end  of  the  carrier  is 
the.  handle  which  has  a  switch  for  the  light  and  two  posts  to  which  a  cable  is  at- 
taclied,  the  other  end  of  which  cable  is  connected  with  an  electric  current  derived 


»iir~i1;rk— nt 


Fig. 


186. — Light  Carrier  for  the  Guiteras 
Urethral  Endoscope. 


either  from  a  portable  storage  battery  or  from  the  street.  The  turning  of  the 
switch  lights  the  lamp  at  the  end  of  the  carrier.  Along  the  gutter  of  the  tube, 
the  electric  lamp,   at  the  distal  extremity  of  its  carrier,   is  passed  almost  to 


Fig.  187. — Portable  Battery  for  the  Guiteras  Urethroscope. 


the  end  of  the  instrument.     In  this  position  it  does  not  interfere  with  the  view 
and  yet  it  gives  a  perfect  illumination  of  the  urethral  field.     There  are  several 


Fig.  ISS. — Wappleu's  Controller  for  Urethroscopy  and 
Cystoscopy. 


190  UKETHROSCOPY 

tubes,  varying  in  size  from  22  to  2cS  French.     A  tube  of  28  French,  or  even 
larger,  is  jireferable  in  urethroscopy. 

The  tubes  of  this  urethroscope  can  Ik;  introduced  into  the  deep  and  the  pos- 
terior urethra  with  greater  ease  than  those  of  any  other  straight  instrument, 

on    account   of   the   rouml- 

jT-^— — • ~^  ^  ^  ^\  ing     of     tlie     lower     })art 

J^]      .j;-; _jfl^     ■^W)'  \         "^  ^^'^  tulje  when  it  curves 

'      .  n^'^^^^'^^P"    vIBh  /         over  the  bottom  of  the  in- 

r,,  •^  /~^       ^~^-~-^,_^^  /  struinent. 

The  ]jattery  providing 
electricity  for  illuminating 
the  urethroscope  is  one 
of  from  four  to  nine  dry  cells,  provided  Avith  a  rheostat  controlling  the  current. 
Such  batteries  may  be  obtained  in  cases  vhich  have  space  for  the  carrying  of 
urethroscopic  tubes,  light  carriers  and  lamps  and  cables.  Fig.  187  shows  the 
battery  made  for  the  author's  urethroscope.  Wlien  the  street  current  is  available, 
a  controller  which  regulates  the  current  must  be  employed  (Fig.  188).  Care 
should  always  be  taken  to  test  the  controller  before  making  the  connection  with 
the  lamp,  as  the  rheostat  at  times  burns  out  and  when  the  little  lamp  is  connected 
it  is  instantly  destroyed  by  an  excess  of  current.  Another  precaution  in  using 
the  controller  is  always  to  turn  off  the  current  in  the  socket  of  the  fixture  to 
which  the  controller  is  attached  as  soon  as  the  use  of  the  apparatus  is  discon- 
tinued. This  prevents  overheating  in  tlie  controller  and  prolongs  the  life  of 
this  appliance. 

The  battery  or  controller  is  connected  with  the  light  carrier  by  means  of  an 
insulated  cord,  the  end  of  which  tits  into  the  hard-rubber  handle  of  the  car- 
rier. A  milled  screw  in  the  handle  of  the  carrier  shuts  off  or  connects  the  lamp 
of  the  urethroscojDe. 

In  addition  to  the  instruments,  the  source  of  light  and  the  controller,  the 
surgeon  should  provide  himself  with  glycerin  in  a  wide-mouthed  vessel  for 
lubrication  and  wath  a  number  of  applicators  about  nine  inches  long.  ^letallic 
applicators  are  the  best  for  both  swabbing  out  the  canal  and  making  ap- 
plications. The  advantage  of  the  metal  applicators  is  that  they  have  a 
special  end  which  prevents  the  cotton  from  coming  off  in  the  tube  and  also 
because  some  of  them  are  so  fine  near  the  end  that,  with  a  thin  layer  of  cot- 
ton about  them,  they  can  be  introduced  into  small  areas  for  the  application  of 
solution. 

A  number  of  very  useful  instruments,  for  intraurethral  treatment  through 
the  endoscopic  tube,  have  also  been  devised  by  Kollmann  and  others.  These 
include  a  pipette  with  a  rubber  bulb  at  its  end  for  removing  drops  of  secretion 
from  the  urethral  glands ;  probes ;  silver  cannulas  wdiich  screw  to  a  small  syringe 
by  means  of  which  local  injection  of  nitrate  of  silver  can  be  made ;  a  set  of 


URETHROSCOPY 


191 


ininnte  knives  for  dividing  strictures  or  iiretliral  bands;  and  a  urethral  snare 
(Fig.  189). 

Physicians  who  wisli  a  special  instrument  for  the  posterior  urethra  will  find 
one  in  the  urethroscope  of  Dr.  G.  K.  Swinburne  of  New  York,  constructed  on 


Fig.  189. — Case  of  Intradrethral,  Instruments. 


r- 


r 


Fig.  lS9a.       Fig.  1896.— Cannula 
Probe.  Used  for  Injecting 

Glands  and  Folli- 
cles. 


Fig.  189c. — Urethral  Knives. 


O 


Fig.  lS9f/. — Gruenfell's  Polypus  Snare. 


192 


URETHROSCOPY 


verv  iiiHcli  tlio  same  ]iatt('rii  aiul  hy  tlic  same  company.     It  is  10  cm.  loiii^  and 
lias  a  beak  2  cm.  in  k'nii,tli.     Tlie  size  used  is  So.  :^S  as  a  rule  (Fig'.  ItiO). 


Fig.   190. — Swinburne's  Posterior  Urethroscope. 

The  Buerger  cysto-urethroscope  gives  a  fine  view  of  the  prostatic  nrethra 
on  all  sides  and  is  constructed  on  entirely  different  lines  from  the  cylindrical 


Fig.   191. — The  Braun-Buerger  Cysto-urethroscope. 

urethroscopes    (Fig.    191).      The   ejaculatory   and   prostatic   ducts,   veru   nion- 
tanum  and  all  portions  of  the  prostatic  urethra  can  be  seen. 


TECHNIQUE   OF   URETHROSCOPY 

The  patient  is  placed  either  in  the  dorsal  position,  with  his  shoulders  ele- 
vated, or,  if  preferred,  in  a  sitting  posture  with  his  body  at  an  angle  of  07^° 
with  the  table.  His  feet  rest  in  inverted  stirrups  below  the  surface  of  the  table 
on  either  side.  If  the  urethroscopy  is  to  be  followed  by  cystoscopy,  as  it  some- 
times is,  he  can  be  placed  at  once  in  the  cystoscopic  position. 

The  examiner  then  sits  in  front  of  the  patient  between  his  legs.  He  takes 
the  urethroscope  with  his  right  hand,  in  such  a  way  that  his  thumb  is  on  the 
obturator  and  his  fore-  and  middle  finger  on  either  side  of  the  tube  behind  the 
disk.  He  dips  it  into  glycerin,  opens  the  meatus  with  the  thumb  and  forefinger 
of  his  left  hand  and  inserts  the  tube  into  and  down  the  urethra  as  far  as  the 
bulb,  while  he  steadies  and  slightly  stretches  the  penis  with  his  left  hand  (Fig. 


PLATK    IV 


URETHROSCOPIC   CONDITIONS. 


Fig.  1. — Appearance  of  the  urethra  after  a  course 

of  treatment  by  electrolysis. 
Fig.  2. — Angioma  of  the  urethra  occupying  only  a 

segment  of  the  canal. 
Fig.  3. — Pedunculated  polyp  of  the  urethra. 
Fig.  4. — Normal  veru  montanum,  anterior  portion. 
Fig.  5. — Normal  view  of  the  urethral  bulb. 
Fig.  6. — Normal  view  of  the  largest  portion  of  the 

veru  montanum. 


Fig.  7. — Longitudinal  section  of  the  normal  ure- 
thra, showing  the  fossa  navicularis  above;  two 
large  urethral  follicles  (crypts  of  Morgagni) 
lower  down.  Numerous  orifices  of  smaller  fol- 
licles are  also  seen,  showing  the  difficulty  of 
thoroughly  treating  all  these  small  openings 
when  in\-olved  in  chronic  urethritis. 

Fig.  8. — Conglomerate  potypoid  granulations. 


TECHNIQUE    OF   URETHROSCOPY 


193 


102).     If  an  examination  of  tlie  posterior  nretlira  is  also  desired,  the  distal  or 
ocular  part  of  the  cystoscope  should  be  depressed  and  the  instrument  pushed 


Fig.   192. — Manner  of  Introducing  the  Urethroscope.     (After  Luys.) 


gently  through  the  membranous  portion  into  the  posterior  portion.     A  swab  is 
then  introduced  into  the  tube  to  dry  up  the  glycerin  or  any  urine  that  may  be 


BiNo  Out  the  Urethr.\. 
(After  Luys.) 


194 


UUETimOSCOPV 


oLscuring  the  field.  The  swabs  are  made  bj  winding  sufficient  cotton  around 
the  end  of  an  applicator  to  have  a  wad  one  sixth  to  one  quarter  of  an  inch  in 
diameter.  Several  of  these  slionld  be  always  ready  to  nse  in  doing  nrethroscopy. 
The  canal  is  swabbed  until  dry  (Fig.  193).  The  lamp  and  its  carrier,  with  the 
cable  attached,  is  then  introduced  into  the  tube  and  fastened  to  tlie  pins  on  the 
disk.  The  current  is  then  turned  on,  and  the  examiner  puts  h  js  eye  to  the  ocular 
end  of  the  tube  and  proceeds  to  inspect  the  urethral  field,  holding  the  urethro- 
scope with  the  right  hand  and  the  organ  with  the  left.  Fig.  194  shows  the 
position  for  examining  the  anterior  urethra,  wliereas  Fig.  195  shows  the  posi- 
tion for  examining  the  posterior  part  of  the  canal. 


Fig.  194. — Position  in  Examining  the  Anterior  Urethra.     (After  Luys.) 


The  Normal  Urethra. — In  order  to  make  a  correct  diagnosis  of  urethral 
lesions  with  the  aid  of  the  urethroscoj)e,  one  must  be  thoroughly  familiar  with 
the  normal  urethra.  An  important  fact  to  bear  in  mind  is  that  the  urethra 
varies  normally  in  appearance,  both  according  to  the  degree  of  anemia  and 
hyperemia,  and  according  to  the  particular  part  which  is  under  observation. 
It  may  be  pale  red,  moderately  red  or  deep  red.  The  paler  tints  have  some- 
times a  grayish  or  a  yellowish  tinge.  The  pressure  of  the  urethroscopic  tube, 
especially  when  it  is  too  large  for  the  canal,  and  when  it  presses  against  one 


PLATE    V 


URETHROSCOPIC   CONDITIONS. 


Fig.  1. — View  very  frequently  seen  of  the  crypts  of 
Morgagni,  urethral  follicles  and  chronically 
inflamed  glands  of  Littre. 

Fig.  2.— Chronically  inflamed  crypt  of  Morgagni 
which  can  be  cured  only  by  applications  of 
electrolysis. 

Fig.  3. — Appearance  of  Littre's  glands  during  a 
chronic  suppurati^'e  process. 

Fig.  4. — Combined  cystic  and  suppurative  con- 
dition of  the  glands  of  Littre.  This  shows 
the  necessity  of  dilatations  in  such  a  con- 
dition. 

Fig.  5. — The  same  condition  as  in  Fig.  4. 


Fig.  6. — A  very  large  cyst  of  Littre's  gland  which 
gave  way  under  dilatation. 

Fig.  7. — Normal  api)earance  of  a  large  crypt  of 
Morgagni  of  a  "V"  shape. 

Fig.  S. — Stricture  of  the  urethra.  Mucous  mem- 
brane is  seen  to  be  darker  with  rigid  walls 
invaded  by  filsrous  tissue.     Veiy  inelastic. 

Fig.  9. — Soft  infiltrate  of  the  bulbous  urethra,  a 
typical  case.  There  is  a  puffiness  resembling 
hemorrhoids. 

Fig.  10. — Sessile  polyp  in  the  bulbar  region. 

Fig.  1L — Small  polyp  situated  on  the  edge  of  a 
large  crypt  of  Morgagni. 


TECHNIQUE   OF   URETHKOSCOPY 


195 


side  of  tlie  urethra,  produces  a  local  anemia  M'liicli  tlie  beginner  must  learn  to 
recognize. 

Various  regions  of  the  urethra  present  certain  important  features  which 
must  be  remembered,    JSTear  the  glans,  that  is,  in  the  region  of  the  fossa  navicu- 


FiG.  195. — Position  in  Examining  the  Posterior  Urethra. 
The  left  thigh  has  been  removed  to  better  show  the  position. 


laris,  the  lining  of  the  canal  is  very  pale  and  smooth.  Beginning  with  the  re- 
gion behind  the  fossa  and  extending  throughout  the  anterior  urethra,  the  mucosa 
is  thrown  into  longitudinal  folds  which  are  necessary  for  allowing  the  canal 
to  be  distended  when  filled  with  urine.  The  size  of  these  folds  varies  in  dif- 
ferent individuals,  as  does  the  size  of  the  penis  and  the  urethra.  The  longi- 
tudinal folds  appear  in  the  urethroscope  between  radiating  lines  from  the  cen- 
tral depression  which  represents  the  lumen  of  the  canal.  Frequently  the 
pressure  of  the  tube  so  distends  these  folds  that  they  are  more  or  less  obliterated. 
As  the  urethra,  when  undisturbed,  is  in  a  collapsed  state,  the  introduction  of 
tlie  tube  widens  the  part  immediately  behind  the  end,  that  is,  the  part  we  are 
looking  at  in  the  form  of  a  funnel  whose  narrow  portion  is  constituted  by  the 
lumen  of  the  undisturbed  part  of  the  canal.  If  we  look  into  the  tube,  there- 
fore, and  if  we  hold  it  so  that  the  lumen  is  central,  we  are  looking  into  the 
funnel  whose  walls  are  formed  by  the  radiating  folds  of  the  spreading  mucosa. 
The  latter  are,  naturally,  most  marked  toward  the  bottom  of  the  funnel  and  are 
obliterated  Avhere  the  edges  of  the  tube  touch  the  mucosa.  The  central  depres- 
sion at  the  bottom  of  the  funnel  sliuuld  always  be  carefully  noted,  as  it  varies 
considerably.  Thus,  in  the  bulb  where  we  begin  the  examinatitm,  the  inferior 
wall  of  the  funnel  bulges  upward  so  that  there  is  a  central  depression  shaped 
like  a  Y  whose  angles  are  rounded.  As  w^e  advance  into  the  cavernous  part  of 
the  urethra,  the  central  depression  becomes  smaller  and  forms  either  a  horizon- 


196  URETHROSCOPY 

tal  slit  or  a  small  circular  fii2,iire.  Finally,  in  the  region  of  the  glans  the  lumen 
assumes  the  shape  of  a  vertical  slit  which  sometimes  appears  as  an  oval  figure. 

In  addition  to  the  folds,  we  have  in  the  normal  urethra  certain  radiating 
striations  which  are  specially  noticeable  in  the  cavernous  portion  when  there  is 
a  good  1)1(1(1(1  snjjply  and  wlien  tlie  urethroscopic  tube  is  sufficiently  large.  These 
striations  are  of  a  pale  or  yellowish  red.  In  persons  with  robust  constitutions 
and  plentiful  blood  supply,  one  also  sees  minute  branched  vessels  coursing 
through  the  mucous  membrane. 

In  the  normal  urethra,  the  surgeon  should  learn  to  distinguish  three  kinds 
of  glandular  openings:  (1)  The  mouths  of  the  ducts  of  Cowper's  glands.  These 
are  not  always  visible,  but  should  be  looked  for  in  the  lower  wall  of  the  bul- 
bous portion,  at  the  bottom  of  the  folds  of  the  mucosa.  (2)  The  urethral  f(jl- 
licles  are  widely  scattered  over  the  anterior  wall  (upper  wall)  of  the  urethra 
and  should  be  looked  for  in  the  cavernous  or  bulbous  portions  by  gently  press- 
ing the  mouth  of  the  tube  against  the  anterior  wall  and  carefully  going  over  the 
canal.  They  look  like  minute  depressions  of  the  size  of  the  head  of  a  pin  or 
smaller,  sometimes  of  the  same  color  as  the  mucosa  around  them,  but  oftener 
of  a  dark  red  with  a  still  darker  center  or  depression.  We  shall  see  that,  in 
chronic  urethritis,  they  may  be  materially  altered.  (3)  Littre's  glands,  which 
are  very  numerous  and  scattered  throughout  the  canal,  are  only  visible  when 
diseased,  but  they  remain  in  evidence  a  long  time  after  the  urethritis,  is  cured. 

All  these  different  characteristics  of  the  normal  urethra  are  far  less  evident 
in  anemic  and  debilitated  individuals  than  in  persons  with  robust  constitutions. 

It  must  be  remembered  that,  when  it  is  desirable  to  examine  the  posterior 
urethra,  this  should  be  done  before  exaiuining  the  anterior  portion  of  the  canal 
by  inserting  the  instrument  at  once  through  the  membranous  into  the  prostatic 
portion.  Tiie  urethroscope  is  then  slowly  withdrawn,  examining  from  ])(_'hiud 
forward,  as  has  been  (lescril)ed. 

Pathological  Conditions. — Other  important  factors  in  urethroscopy  include 
the  localizati(jn  of  lesions  along  the  canal  in  urethras  of  large  size  in  which  no 
strictures  are  present.  One  of  the  important  lesions  Avhich  should  be  detected 
with  the  urethroscope,  if  j^jresent,  is  a  polyp  of  the  mucosa  f(U'  which  urethras 
are  frequently  dilated  for  a  long  time,  under  the  impression  that  it  is  a  nar- 
rowing of  the  canal.  Simple  and  tubercular  ulcers,  erosions,  granular  patches 
and  the  dilated  glandular  ducts  can  also  be  seen. 

Tubercular  ulcers  occur  in  the  urethra,  although  rarely.  Soft  and  hard 
chancres  are  always  situated  near  the  meatus  and  can  be  easily  seen  without  the 
urethroscope. 

In  strictures,  urethroscopy  serves  to  show  the  narrowing  and  the  presence 
near  by  of  chronic  congestion  or  inflammation.  T'nfortunately,  the  tube  which 
has  to  be  used  in  most  cases  of  stricture  is  so  small  that  it  does  not  allow  us  to 
examine  the  field  very  minutely. 


TPXUTNIQUE    OF    URETTTROSCOPY  197 

Urkthkosoopiu  Treatmknt  of  Pathological  Conditkjns. — Foreign 
bodies  in  the  iiretlira  can  be  detected  through  the  nrethroscope  and  occasionally 
removed  by  introducing  alligator  forceps,  grasping  them  and  i)ulling  them  out 
through  the  tube.  Polyps  can  be  removed  from  the  urethra  by  means  of  a  snare ; 
ulcerated  surfaces  and  granular  patches  can  be  curetted  and  cauterized  ;  the 
dilated  ducts  of  urethral  glands  can  be  cauterized  and  destroyed  by  electrolysis 
or  slit  up  with  minute  knives. 

Urethroscopy  is  of  great  value  in  the  diagnosis  of  the  lesions  of  chronic 
urethritis,  showing  as  it  does  the  stage  of  the  disease  and  the  tyjie  of  the  lesions 
present.  This  subject,  however,  is  discussed  in  the  chapter  on  Chronic  Ure- 
thritis, to  which  the  reader  is  referred  for  further  particulars. 

There  is  a  certain  amount  of  difficulty  in  learning  to  do  urethroscopy  and 
in  interpreting  what  is  found.  The  procedure  requires  much  patience,  practice 
and  precision.  In  order  to  become  skilled  in  it,  one  must  examine  a  large  num- 
ber of  cases,  remembering  always  that  the  introduction  of  the  urethroscope  is 
contraindicated  in  all  acute  conditions.  It  is  a  question  whether  urethroscopy 
is  of  such  great  practical  importance  as  has  been  stated  by  some  authors.  In 
the  majority  of  cases,  I  have  gained  nothing  from  my  examinations  with  the 
urethroscope  and  have  often  felt  that  the  work  has  been  a  loss  of  time.  In  most 
instances,  nothing  is  seen  but  a  slightly  granular  condition  of  the  urethra  in 
certain  localities,  or  else  areas  of  chronic  inflammation  which  can  only  be 
treated  by  dilatation  and  irrigation.  Occasionally  we  see  something  of  im- 
portance like  a  polyp  of  the  urethra  and  then  we  feel  how  important  it  is  to 
urethroscope  all  patients  with  chronic  urethral  trouble  as  a  matter  of  routine. 


CHAPTER    X 

CYSTOSCOPY 

Cystoscopy  is  at  the  present  day  a  practical  procedure.  During  tlic  last 
twenty-five  years  of  the  nineteenth  century,  many  investigators  who  were  in- 
terested in  urinary  diseases  were  bending  their  energies  to  discover  some  instru- 
ment that  woukl  reveal  to  them  the  character  of  the  interior  of  the  bladder  and 
the  ureters  leading  to  the  kidneys.  When  such  instruments  were  finally  made 
practical,  the  advance  became  very  rapid,  so  that  to-day  the  bladder  can  be  ex- 
plored by  every  conceivable  visual  apparatus ;  and,  although  we  can  see  what 
we  consider  necessary  for  us  in  urinary  work,  the  probabilities  are  that  in  a  few 
years  this  procedure  wall  be  looked  upon  as  crude  and  behind  the  times.  It 
is  well  to  consider  what  cystoscopy  is ;  the  different  instruments  that  were  used 
in  the  past  and  are  used  at  present,  as  well  as  the  details  of  performing  cysto- 
scopic  examinations. 

The  cystoscope  (from  cystls,  bladder  and  skopein,  to  view)  is  a  tube  fitted 
with  lenses,  or  lenses  and  prisms,  for  viewing  the  interior  of  the  bladder  when 
illuminated  with  an  electric  lamp. 

While  cystosco]3y  is  essentially  a  method  of  examining  the  bladder,  it  also 
shows  the  vesical  aspect  of  the  prostate  and,  through  the  inspection  of  the  ure- 
teral orifices  and  the  urine  coming  from  the  ureters,  it  aids  in  diagnosing  dis- 
eases of  the  kidneys. 

It  must  always  be  borne  in  mind  that  the  object  of  cystoscopy  is  to  examine 
the  bladder,  and  that  it  is  not  done  for  the  ptirpose  of  cathcterizing  the  ureters, 
unless  clinical  and  urinary  evidence  point  to  ureteral  or  renal  involvement. 

HISTORY    OF    CYSTOSCOPY 

The  early  attempts  at  cystoscopy  were  cond)ined  with  those  to  illuminate 
the  urethra.  The  first  of  these  dates  from  1<S05,  when  Bozzini,  of  h^'rankfort, 
invented  an  apparatus  which  was  meant  to  illuminate  the  urethra  and  bladder. 
A  number  of  attempts  of  similar  character  were  made  with  little  success  until 
Desormeux,  Furstenheim  and  Cruise  (1853—65)  constructed  the  first  endo- 
scopes that  made  an  examination  of  the  bladder  possible.  In  1SC7,  Brlick,  a 
dentist  in  Breslau,  devised  an  instrument  for  examining  the  mouth,  called 
198 


HISTORY   OF    CYSTOSCOPY  199 

a  stomatoscope,  wliifli  was  illuniinatcd  by  moans  of  an  incandescent  plnliiniiii 
loop,  heated  to  white  heat  b,y  means  of  a  galvanic  current,  and  later  constructed 
another  for  exauiining  tlie  bladder,  called  a  diaphanoscope.  Although  it  was 
found  to  1)0  uupractical,  it  is  interesting,  because  the  Nitze  instruuients,  which 
are  now  in  nse,  are  constructed  on  the  same  principles. 

In  ISTG,  Nitze  devised  an  electric  cystoscope  and  urethroscope,  and  demon- 
strated the  instrument  in  1877.  This  cystoscope  was  later  improved  and  sim- 
plified by  Leiter  of  Vienna,  so  that  the  first  electric  cystoscope  bears  the  name 
of  Nitze-Leiter  and  the  date  of  1879.  The  lighting  device  of  this  cystoscope 
was  also  an  incandescent  platinum  loop  Avhich  was  surrounded  by  a  stream  of 
water  so  as  to  keep  the  end  of  the  instrument  cool.  A  flow  of  water  was  neces- 
sary to  keep  the  temperature  of  the  beak  of  the  instrument  below  the  danger 
line.  The  original  JSTitze-Leiter  cystoscope  was  complicated,  cumbersome  and 
unsatisfactory  in  many  respects. 

In  1879,  Edison  first  patented  his  incandescent  lamp,  which  revolutionized 
the  methods  of  constructing  illuminating  instruments  in  general  and  cystoscopes 
in  particular.  Since  then,  the  incandescent  lamp  system  has  been  used  in 
cystoscopy. 

In  1887,  came  the  introduction  of  the  cystoscopes  of  jSTitze  and  Leiter,  both 
constructed  on  similar  principles,  and  also  the  direct  cystoscope  of  Brenner, 
which  have  served  as  models  for  all  the  cystoscopes  since  devised.  These  cys- 
toscopes had  shafts  shaped  like  a  coude  catheter  and  were  of  the  observation  type 
for  viewing  the  interior  of  the  bladder  through  a  water  medium. 

Catheterization  of  the  Ureters. — The  steps  leading  up  to  the  catheterization 
of  the  ureters  began  at  about  the  time  that  jSTitze,  Leiter  and  Brenner  had  per- 
fected their  observation  cystoscopes  in  1887  and  were  not  associated  with 
cystoscopy. 

Iverson,  in  1888,  began  to  catheterize  the  ureters  by  opening  the  bladder 
suprapubically  and  thus  reaching  their  mouths,  while  Bozeman  reached  them 
through  a  vesico-vaginal  opening;  these  procedures  were  in  the  line  of  major 
operations  and  consequently  dangerous  in  character. 

At  about  the  same  time,  in  the  development  of  ureteral  catheterisui,  Pawliek 
(Wiener  Med.  Prxssz,  1886)  found  that,  by  placing  a  woman  in  the  genu- 
pectoral  position,  he  could  lift  up  the  posterior  vaginal  wall  with  a  speculum 
and  expose  to  view  the  anterior  wall;  then,  having  introduced  a  catheter  into 
the  bladder,  ho  could  guide  the  point  of  the  instrument  by  his  finger  in  the 
vagina  until  it  reached  the  ureteral  orifice,  when  he  could  pusli  it  into  the 
ureter.  This  procedure  was  exceedingly  difficult  of  execution,  rather  dangerous 
on  account  of  the  blind  manner  in  which  it  was  performed,  and,  of  course,  only 
applicable  in  women. 

Later,  Kelly,  of  Baltimore,  uiodified  tlie  metliod  tlmt  luul  been  employed 
wdthout  much  success  by  Pawliek  and  devised  a  method  of  cathcterizing  the 


200  CYSTOSCOPY 

ureters,  familiar  to  us  all,  which  consisted  in  passing  a  tube  through  the  urethra 
into  the  bladder,  illuminating  its  interior  by  reflected  light  from  a  head  mirror, 
and  searching  for  the  ureters  witli  the  aid  of  a  long  stilet  which  served  to  unfold 
the  bladder.  AVhen  the  ureteral  orifices  had  been  found,  the  stilet  was  re- 
placed by  a  catheter. 

It  was  not,  however,  until  1SU2  that  catheterization  was  performed  through 
a  cystoscope  and  then  by  means  of  the  direct  instrument.  The  first  of  these 
was  that  of  Brenner  in  1802;  then  that  of  Xitze  in  1895,  of  Casper  in  1896 
and  finally  the  Xitze-Albarran  in  1897. 

A   COMPARATIVE   CONSIDERATION    OF   MODERN   CYSTOSCOPES 

Having  gone  over  our  historical  review  and  found  that  the  principal  men 
to  whom  we  are  indebted  for  early  knowledge  of  the  examination  of  the  Ijladder 
were  ISTitze,  Brenner,  FeuAvick,  Pawlick,  Kelly,  Casper  and  Albarran,  let  us  con- 
sider the  later  work  along  these  lines. 

We  will  put  first  on  our  list  Brenner  and  Xitze,  as  the  two  leaders  in  the 
respective  lines  of  direct  and  indirect  cystoscopy. 

Brenner's  direct  instrument  (Fig.  196)  was  perfected  in  1887  and  was  the 
first  direct-observation  cystoscope  of  practical  value  for  examining  the  bladder 


Fig.  196. — Brenner  s  Observation  and  Catheterizing  Cystoscope. 

through  a  water  medium.  The  instrument  had  an  optical  apparatus  consisting 
of  a  telescope,  which  looked  straight  into  the  bladder  without  requiring  any 
prisms  to  reflect  the  image. 

The  First  Direct-Observation,  Irrigating  and  Catheterizing  Cystoscope. — 
In  1892,  Brenner  added  a  snuill  separate  compartment  on  the  convex  side  of 
his  instrument  which  contained  a  mandrel.  The  mandrel  could  be  withdrawn 
and  the  bladder  washed  out  throngli  this  channel,  or  a  catheter  could  be  intro- 
duced through  it  into  a  ureter.  The  instrument  could  also  be  slipped  out  over 
this  catheter,  leaving  it  in  the  ureter.  It  was  for  a  long  time  considered  the 
best  instrument  for  ureteral  and  kidney  work  in  women.  The  Brenner  instru- 
ment was  thus  transformed  from  an  observation  cystoscope  to  an  irrigating,  and 
a  single  catheterizing  cystoscope,  which  marked  the  greatest  achievement  up  to 
that  time  in  cystoscopy. 

The  Indirect  Cystoscope. — The  steady  improvement  of  the  indirect  instru- 
ment in  the  hands  of  jSI^itze,   Casper,  Leiter,  Fenwick  and  others,  made  the 


CONSIDEKATION    OF    MODERN    CYSTOSCOPES  201 

infliroc't  cystoscopc  of  tlie  Nitzc  typo  more  useful  than  tlie  direct.  The  advan- 
tage of  the  indirect  instrument  was  that  a  better  view  of  the  whole  bladder 
interior  could  be  obtained,  especially  of  the  anterior  wall. 

TuE   Construction  of  the  Nitze   Cystoscope. — The  ISTitze  cystoscopc 
(Fig.  197)  consists  of  an  elbowed  tube,  having  at  its  vesical  end,  in  the  elbow, 


11 


Fig.  197. — Nitze's  Observation  Cystoscope. 

an  electric  lamp,  contained  in  a  metal  sheath  which  is  fenestrated  upon-  its  an- 
terior surface.  Close  to  the  elbow,  upon  the  upper  surface  of  the  straight  por- 
tion of  the  tube,  is  a  prism,  which  lies  so  that  the  hypothenuse,  which  is  silvered, 
forms  a  mirror  and  reflects  the  rays  of  light  entering  the  prism  from  the  blad- 
der into  the  lumen  of  the  cystoscopic  tube.  In  this,  by  means  of  an  arrange- 
ment of  lenses  similar  to  those  of  a  telescope,  the  rays  are  transmitted  to  the 
eye  applied  at  the  ocular  end  of  the  cystoscope.  Owing  to  the  fact  that  a  prism 
is  employed  as  a  mirror,  we  obtain  an  inverted  image.  This,  at  first,  may  lead 
to  some  confusion;  but,  after  a  little  practice,  it  will  be  found  that  one  grows 
sufficiently  accustomed  to  this  change  to  be  able  to  disregard  it  entirely.  To  over- 
come the  difficulty  of  dealing  with  the  inverted  image,  the  use  of  the  straight- 
tube  telescopic  cystoscope,  minus  the  prism,  has  been  advocated  by  Brenner  and 
others.  All  the  instruments  of  the  Brenner  type,  while  giving  us  an  image  in 
its  proper  relative  position,  have  the  disadvantage  that  there  are  parts  of  the 
bladder  wall  which  cannot  be  brought  into  the  field  of  vision.  The  indirect 
cystoscopes  made  by  the  Wappler  Company  now  have  a  correcting  appliance 
in  their  telescopes  by  means  of  which  the  image  is  seen  as  it  naturally  exists, 
that  is,  not  inverted. 

The  Observation,  Irrigating-,  Catheterizing  Indirect  Cystoscope. — ^^Titze 
added  an  irrigating  apparatus  to  his  cystoscope,  making  an  irrigating  instru- 


Fic.  198. — Nitze's  Irrigating  Cystoscope,  Showing  the  Nozzles  for  the  Entrance  and   Exit 

OF  THE  Solutions. 

ment  (Fig.  198).  Later  he  made  further  improvements,  enabling  him  to  treat 
and  operate  on  bladder  lesions  and  crush  stones  and  remove  foreign  bodies.  He 
also  added  a  channel  to  his  instrument  through  which  a  catheter  could  be  passed 
into  a  ureter.     Nitze,  then,  advanced  a  step  beyond  Brenner,  in  that  he  had 


202 


CYSTOSCOPY 


combined  (1)  observation  cystoscopc,  (2)  iri-iiiatina,'  cystoscopo,  (3)  sinjile- 
catbeteriziiig-  cystosco})e,  (4)  ojjeratiug  cystoscope  and  (5)  photogTa])binj^ 
cystoscope. 

Nitze  Operating  and  Photographic  Cystoscope  (  Fii;;.  109). — The  cautery 
snare  is  used  to  cauterize  the  base  of  growths  in  the  bladder. 


Fig.  199. — -Nitze's  Operating  Cystoscope,  Showing  the  Snare  and  Lithotrite. 


The  lithotrite  can  be  used  for  crushing  small  stones,  while  the  evacuator 
washes  out  the  fragments. 

The  photograjDhic  cystoscope  requires  much  care  and  rarely  produces  photo- 
graphs which  will  repay  one  for  the  time  expended  upon  them. 

Mechanism  for  Influencing  the  Direction  of  the  Ureteral  Catheter. — The 
l^itze  cystoscope  was  a  better  one  for  catheterizing  the  ureters,  as  it  could  not 
only  show  the  ureters  in  women  as  well  as  the  direct  instrument,  but  in  men  it 
could  turn  its  beak  over  the  base  of  an  enlarged  prostate  and  catheterize  the 
ureter  when  it  could  not  be  done  with  a  direct  instrument.  It  was,  however, 
exceedingly  difficult  to  introduce  a  catheter  into  the  ureter  by  means  of  ISTitze's 
indirect  cystoscope.  Gasper  modified  Nitze's  instrument  and  constructed  a  slot 
along  the  concave  shaft  of  the  instrument,  which  helped  to  give  a  turn  or  bend 
to  the  catheter,  thus  facilitating  its  entrance  into  the  ureter. 

Albarran  modified  ISTitze's  catheterizing  instrument  by  constructing  a  lever 
upon  the  concave  surface  of  the  shaft  at  the  point  where  the  catheter  comes  out, 
which  can  change  its  direction  by  the  turning  of  a  screw  on  the  side  of  the  cysto- 
scope. This  lever  in  Albarran's  instrument  is  a  little  tongue  of  metal  which  is 
controlled  by  the  screw  near  the  handle,  by  means  of  which  the  end  of  the  cathe- 
ter can  be  pushed  away  from  the  prism  or  lamp  and  straighten  out  at  any  angle 
to  the  cystoscope  the  op)erator  desires.     Albarran's  instrument,  in  addition,  had 


CONSTDERATTON    OF    MODEKN    CYSTOSCOPES  203 

an  irrigating  attachmcMit  somewhat  similar  in  construction  to  that  seen  in  the 
newer  types  of  Nitze's  catheterizing  cystoscope  (Fig.  200). 


Fig.  200. — Nitze-Albarran  Catheterizing  Cy.stoscope,  Showing   the  Lever  for  Moving    the 
Ends  of  the  Catheters  toward  the  Ureteral  Openings. 

The   Air   Direct-Observation   and   Single-Catheterizing    Cystoscope. — At 

about  the  time  that  the  Nitze-Albarran  cystoscope  was  considered  the  highest 
development  of  the  combined  observation  and  catheterizing  instruments,  the 
catheterizing  of  the  ureters  was  still  considered  a  mysterious,  sleight-of-hand 
trick,  and  was  not  believed  possible  by  many  practitioners,  who  were  inclined  to 
put  in  the  fakir  class  anyone  who  professed  to  be  able  to  do  it.  Indeed,  so  won- 
derful was  it  considered,  that  the  announcement  that  a  lecture  on  catheteriza- 
tion of  the  ureters  was  to  be  given  with  a  demonstration  of  the  same  was  suffi- 
cient to  pack  an  amphitheater. 

How  strange  it  must  have  seemed  to  the  unbelievers  of  the  profession  to  see 
a  direct  cystoscope  put  upon  the  market  (by  an  instrument  company  in  Roches- 
ter, ]Sr.  Y.),  which  was  not  only  capable  of  showing  the  ureters  in  a  bladder 
dilated  with  air,  but  by  means  of  which  the  ureters  could  be  catheterized  even 
by  the  lay  salesman  who  sold  it!  It  seemed  then  that  cystoscopy  had  been 
brought  to  such  a  simple  form  that  any  practitioner  could  examine  the  interior 
of  the  bladder  and  perform  a  ureteral  catheterization.  It  was  found,  however, 
on  trying  the  instrument,  that  such  was  not  the  case  and  that  a  knowledge  of 
the  subject  on  the  part  of  the  best  physician  or  surgeon  did  not  avail  as  much 
as  practice  in  the  hands  of  a  lay  agent  of  the  company^  Many  of  these  so-called 
direct-air  cystoscopes  could  be  used  by  means  of  a  water  medium  as  well  as  by 
air.  Since  then  air  cystoscopes  have  been  used  in  France,  and  much  improved 
by  Luys  and  Cathelin. 

The  air  cystoscope  consists  of  a  tube  which  has  in  its  upper  wall  a  smaller 
passage  for  the  conduction  of  a  wire  that  connects  with  the  electric  lamp  and  on 
its  lower  or  convex  wall  another  tube  for  the  introduction  of  the  urethral  cathe- 
ter. The  light  from  the  lamp  emerges  through  a  glass  window,  in  the  convexity 
of  the  main  tube  near  its  end.  The  lamp,  when  burned  out,  is  removable  by 
unscrewing  the  tip  and  pulling  it  out.  To  facilitate  the  introduction  of  the 
cystoscope,  an  obturator  is  furnished,  which  closes  the  distal  orifice  and  pre- 
vents scraping  of  the  membrane  against  the  edges  of  the  opening.  A  glass- 
covered  cap  may  bo  jilaced  over  the  ocular  end  to  enable  the  operator  to  dis- 
tend the  bladder  forcibly  with  air,  when  that  condition  is  not  effected  by 
posture.      The   inflation   is   made  by   a  rubber   bulb   attached   to   a   stop  cock. 


204  CYSTOSCOPY 

The  iiistruiiient  resembles  .soinewliat  the  inegalcscojK!  of  Jjoisscau   du    Uocliet 
(Fio-.  201). 

The  Coi.d  LaiMP. — The  use  of  cystoscopy  hy  air  dihitatiou  wao  first  made 
possible  by  the  production  of  a  diminutive  incandescent  lamp,  practically  heat- 


^gJP  1 7 

Fig.  201. — A  Direct  Air  Cystoscope  of  American  Make. 

less,  by  E.  C.  Preston  of  Kochester.  He  first  began  to  niannfacture  it  for 
throwing  light  into  the  nostrils,  by  using  it  on  a  long  holder  for  illuminating 
the  mouth  and  throat,  and  also  attached  it  to  a  tongue  depressor.  Later,  working 
with  Dr.  Koch  of  Rochester,  they  applied  it  to  urethroscopes  and  cystoscopes, 
calling  it  the  Mignon  lamp. 

As  soon  as  the  cold  lamps  were  introduced,  I  had  them  placed  in  all  of  my 
imported  cystoscopes — the  ]S[itze,  Albarran,  Leiter  and  Fenv\'ick— and  have 
been  using  them  as  cold-lamj)  cystoscopies  since  that  time.  The  cold  lamps  do 
not  give  as  powerful  a  light,  however,  as  the  hot  lamps,  and  at  times  superficial 
ulcerations  might  be  overlooked.  The  cold  lamps  have  been  very  much  im- 
proved since  they  were  first  introduced  and  are  now  much  more  powerful  and 
durable. 

It  is  claimed  that  it  radiates  so  little  heat  that  it  may  be  held  within  a  quar- 
ter inch  of  live  tissues  for  an  indefinite  period  wdthout  any  discomfort,  to  say 
nothing  of  pain.  It  is  really  this  property  of  the  electric  lamp  that  made  the 
air  instrument  feasible.  A  hot  lamp  requires  the  protection  of  fluid  before  it 
can  be  safely  introduced  into  the  bladder.  Thus,  the  use  of  fluid  is  eliminated, 
together  with  its  several  disadvantages,  such  as  rapid  clouding  by  inflowing  pus 
or  blood,  etc. 

From  the  brief  description  given,  it  is  evident  that  the  air  instrument  is  ex- 
tremely simple,  which,  I  believe,  is  one  of  its  chief  advantages.  Its  freedoui 
from  complexity  relieves  it  from  many  of  the  sources  of  difficulties  encountered 
in  the  use  of  the  older  forms.  Many  of  them  have  no  lenses  between  the  eye 
and  the  subject  of  investigation.  Lenses  must  be  perfect  in  order  to  be  of  any 
service  whatever,  and  perfection  in  them  is  both  expensive  and  diflicult  of  attain- 
ment ;  also,  after  perfection  has  been  attained,  the  usefulness  of  the  instrument 
may  be  destroyed  in  an  instant  by  their  displacement  in  the  slightest  degree. 

The  Combined  Observation  and  Double-Catheterizing-  Cystoscope. — The 
advance  in  cystoscopy  next  turned  to  perfecting  the  double-catheterization  aj^pa- 


CONSIDERATION   OF    MODERN    CYSTOSCOPES 


205 


rains  wliieli  had  Ix-cii  devised  by  Boisseau  du  Rochet  some  time  before  this.  The 
cathcteriziiig-  apparatus  consisted  of  .a  double  tube,  or  else  a  sing-le  tube  divided 
in  two  parts  by  a  partition.  In  either  case,  two  nreteral  catheters  could  be 
placed  in  the  cystoscope  at  the  same  time.  Such  an  arrangement  for  the  carry- 
ing of  two  catheters  v^^as  incorporated  in  both  the  direct  and  indirect  instruments. 

Direct-catheterizing  cystoscopes  througk  a  water  medium  were  brought  out 
in  this  country  by  Ayres,  Brown,  Cabot,  Kolisher,  Schmidt,  myself  and  others, 
while  that  of  the  indirect  type  was  first  brought  out  by  Bierhoif.  The  addition 
of  the  double-catheter  channel,  however,  did  not  interfere  with  the  observation 
])urpose  of  the  instrmnents  any  more  than  when  the  singie-catheterizing  tnbe 
was  used. 

The  first  direct-observation  and  douhle-catheterizing  cystoscope  of  American 
mnJiC  was  brought  out  by  Brown  of  ISTew  York.  It  was  manufactured  by 
Wappler  of  the  Wappler  Electric  Controller  Company,  of  tbis  city.     The  shaft 


Fig.  202. — The  Brown  Cystoscope.     Below  is  the  shaft  with  its  obturator,  and  above  it  is  the  direct 
telescope  showing  the  catheters  in  their  grooves. 

of  this  instrument  was  constructed  on  the  same  plan  as  that  of  the  direct-ob- 
servation type  and  the  light  showed  through  a  window  in  the  convex  side  of  the 
beak.  The  instrument,  like  that  of  the  observation  type,  was  introduced  into 
the  bladder  with  a  mandrel  in  place.  After  the  end  of  the  instrument  was  in 
the  bladder,  the  mandrel  was  withdrawn  and  the  telescope  carrying  the  catheter 
was  introduced.  It  now  has  a  double  passage  in  order  to  carry  tAvo  catheters 
(Fig.  202). 

Indirect-Observation  and  Double-Catheterizing  Cystoscope. — Bierhoft'  was 
the  first  in  this  country  to  construct  a  double-catheterizing  cystoscope  of  the  in- 


FiG.  203. — Bierhoff's  Indirect  Catheterizing  Cystoscope.' 


direct  type.     (Aled.  News,  March  8,  1902.)     The  size  of  ihe  instrument  is  23 
French.     It  is  arranged  for  double-current  irrigating. 

It  is  a  modificaticm  of  the  improved  jSTitze-AlbaiTau  catheterizing  cystoscope 
and  consists  of  a  cystoscope  upon  which  is  the  movable  catheterizing  portion. 


206 


CYSTOSCOPY 


(See  Fig.  203.)  The  latter  contains  two  separate  tubes  in  wliicli  the  catheters 
pass  and  which  terminate  at  the  outer  end  in  two  separate  cannuhx;  capped  h}' 
the  nsiial  screw  caps.  At  the  inner  end  they  terminate  in  two  small,  movable 
tongue,  finger  or  knee  mechanisms,  which  are  controlled  and  moved  by  the 
large  screw,  as  in  the  single-catheterizing  instrument.  There  are  also  two  stoj)- 
cocks  to  replace  the  screw  caps  upon  the  cannulte,  when  the  double-current  irri- 
gation is  to  be  employed.  The  catheterizing  portion,  being  movable,  can  l)e 
sterilized  by  boiling.  The  eystoscope  itself  must  be  sterilized  by  formalin  vapor 
or  by  immersion  in  an  antiseptic  solution  (ITolstein  solution). 


Fig.  204. — Bransford  Lewis  Cystoscope. 

1.  The  shaft.  4-  Retrograde  vision. 

2.  The  direct  observation  part.  5.  Indirect  observation. 
S.  Direct  catheterizing.  6.  Indirect  catheterizing 


A 


CONSIDEKATTON    OF    MODERN    CYSTOHCOPES  207 

Tlie  first  direct-observation  ;ni<l  (louljlc-callictcri/inii;-  air  eystoscope  in  tliis 
country,  was  that  of  Bransford  J.ewis,  nuule  by  one  of  the  Rochester  companies 
(Fig.  204).  This  was  shortly  afterwards  made  into  a  water  eystoscope  and  is 
manufactured  by  Kny-Scheerer.  It  is  a  very  complete  instrument  and  is  to-day 
])r()l)ably  the  eystoscope  that  has  more  additional  contrivances  for  bladder  work 
than  any  other. 

The  Combined  Direct  and  Indirect  Teaching  Cystoscope. — Five  years  ago 
I  had  a  condnned  direct  and  indirect  observation  cystoscope  constructed  for 
examining  the  interior  of  the  bladder.  The  need  of  such  an  instrument  was 
shown  to  me  by  the  difficulty  that  practitioners  enconnter  in  making  a  thorough 
and  systematic  examination  of  the  bladder  which  is  so  important  for  bladder 
diagnosis,  and  for  familiarizing  oneself  with  the  position  and  appearance  of  the 
mouths  of  the  ureters  before  using  the  catheterizing  cj^stoscope. 

For  a  long  time  cystoscopy  was  not  taken  np  in  the  United  States,  although 
it  was  quite  extensively  practiced  in  Europe.  The  two  principal  reasons  for  the 
neglect  of  this  important  step  in  diagnosis  were  the  price  of  the  imported  in- 
strument and  the  lack  of  teachers  in  cystoscopy,  such  as  could  be  found  in  Berlin 
and  Paris. 

Eventually  genito-urinary  surgeons  visited  Berlin  and  Paris  to  acquire  the 
knowledge  and  art  in  which  they  found  they  were  lacking.  Finally  the  instru- 
ment-makers and  electricians  in  the  United  States,  principally  Wappler  in  ISTew 
York  and  Preston  in  Rochester,  through  the  suggestions  of  surgeons  interested 
in  cystoscopy,  started  to  manufacture  cystoscopes  and  they  have  placed  very 
satisfactory  and  creditable  instruments  on  the  market. 

At  the  time,  however,  wdien  the  American  manufacturers  began  to  intro- 
duce their  instruments,  the  cystoscopists  in  Europe  had  passed  through  the 
])eriod  of  observation  cystoscopy  and  were  interested  in  the  catheterizing  in- 
struments. The  result  of  this  was  that  the  catheterizing  cystoscopes  were  prin- 
cipally brought  out  in  this  country,  and  were  bought  by  practitioners  without 
training  in  cystoscopy,  who  soon  found  themselves  inifitted  for  the  work.  The 
instruments  then  became  toys  which  they  could  not  use,  and  wdien  trials  were 
made,  it  was  generally  for  the  purpose  of  endeavoring  to  pass  catheters  into  the 
ureter,  in  wdiich  undertaking  they  ^vere  usually  unsuccessful,  in  consequence 
of  which  most  of  them  gave  up  cystoscopy  as  hopeless. 

When  I  first  started  the  cystoscopic  room  in  my  clinic  nine  years  ago,  I  used 
the  Leiter  and  ISTitze  indirect-observation  instruments.  The  assistants  follow- 
ing used  a  direct-observation  and  catheterizing  instrument  of  American  make, 
with  the  result  that  they  found  numerous  cases  of  papillomas  of  the  bladder. 
1'hese  proved  to  be  from  traumatism  due  to  the  rough  manipulation  of  the  tel- 
escopic end  of  the  direct  cystoscope.  Accordingly,  I  made  a  rule  that  no  one 
should  do  cystoscopic  work  until  he  had  served  a  certain  time  as  an  assistant 
in   the   cystoscopic   room,    washing   out   the   bladder   and   preparing   the   cases 


208  CYSTOSCOPY 

for  cystoscopy.  After  this  no  more  vesical  papillomas  of  this  nature  were 
seen. 

I  also  found  that,  with  the  development  of  the  direct-catheterizing  cystoscojie, 
the  object  of  cystoscopy,  that  is,  the  examination  of  the  interior  of  the  bladder, 
was  lost  sight  of,  and  the  men  working  in  cystoscopy  siiii])ly  hjokcd  foi-  the 
nreters  in  order  that  tliey  might  catheterize  them  as  a  matter  of  practice. 

Therefore  I  had  this  observation  cystoscope  made  in  order  that  the  assistants 
might  learn  to  examine  the  bladder  before  taking  np  the  catheterization  of  the 
nreters  and  each  man  conld  sj)end  six  months  on  cystoscopy,  three  with  the  ol> 
servation  and  three  with  the  catheterizing  instrnment. 

Descriptiojt  of  the  Cystoscope. — The  teaching  cystoscope  is  a  com- 
bination of  Xitze,  Brenner  and  Boissean  dn  Rochet  instruments,  or,  more  prop- 
erly speaking,  of  F.  Tilden  Brown,  Bransford  Lewis  and  William  K.  Otis,  with 
modifications  that  have  seemed  to  me  practical,  the  principal  one  being  the 
elimination  of  the  obturator  as  an  unnecessary  attachment. 

My  cystoscope  consists  of  four  parts  (Fig.  205)  :  (1)  A  hollow  shaft  with  a 
lamp  in  its  beak;  (2)  a  combined  obturator  and  indirect-observation  telescope; 


^d 


er 


Fig.  205. — Guiteras  Teaching  Cystoscope. 

1.  Straight,  hollow  shaft  for  reception  of  the  3.   Direct  telescopic  tube. 

telescopic  tube.  4.   Direct  telescope  ^vith  grooves  for  the 

2.  Indirect  telescopic  tube.  catheters. 

(3)  a  direct-observation  telescope;  and  (4)  a  direct-observation  telescope  with 
catheterizing  attachment. 

To  go  into  the  separate  parts  more  in  detail :  (1)  The  first  is  a  straight  tube 
with  curved  beak,  in  which  there  is  an  electric  light  tliat  tlirows  its  rays  both 
from  the  convexity  and  concavity.     It  has  an  open  space  on  the  straight  part  of 


CONSTDEKATTON    OF    MODERX    CYSTOSCOPES  209 

the  shaft  near  tlie  concavity,  servinii;  as  a  window  llii'diiiih  A\liic1i  one  can  look 
from  the  indirect  visnal  part  of  the  telescope  that  tits  directly  beliind  it. 

(:2)  The  second  is  a  combined  telescope  and  obturator  with  a  visnal  ap- 
])aratns,  the  window  of  which  is  abont  one  third  of  an  incli  from  its  end.  The 
end  is  solid,  cnt  obliquely  and  of  an  angle  that  exactly  fits  in  the  distal  ex- 
tremity of  the  hollow  tube  which  it  fills,  thus  serving  both  as  an  obturator  and 
for  indirect  examinations. 

(3)  The  third  is  a  telescope  similar  to  those  in  all  the  direct  Wappler  cys- 
toscopes  for  the  direct  examination  of  the  bladder,  which,  wdien  pushed  through 
the  hollow  shaft,  protrudes  through  the  opening  in  its  convexity. 

(4)  The  catheterizing  part  closely  resembles  the  direct  telescopic  portion, 
excepting  that  it  has  on  its  surface  a  fin  with  a  groove  on  either  side  of  it.  These 
two  grooves  connect  with  the  nozzles  on  the  proximal  end,  through  which  the 
catheters  are  inserted.  The  catheters  then  pass  along  the  grooves  to  the  end 
of  the  instrument,  being  held  in  place  by  the  inner  wall  of  the  hollow  shaft  as 
far  as  its  distal  end,  from  which  point  they  are  pushed  out  into  the  ureters 
when  the  instrument  is  in  the  bladder. 

This  instrument  is  very  practical,  as,  with  the  indirect  visual  apparatus  in- 
serted, it  answers  the  same  purpose  as  a  Nitze  observation  cystoscope.  After 
the  bladder  has  been  thoroughly  examined  by  the  indirect  method,  the  indirect 
apparatus  is  removed  and  the  direct  telescope  of  the  instrument  is  introduced 
for  the  corresponding  examination.  The  cystoscope  stands  for  my  teachings  in 
cystoscopy  during  the  last  ten  years :  First,  that  a  bladder  should  always  be  ex- 
amined with  the  indirect  cystoscope  before  the  ureters  are  catheterized ;  second, 
the  ureters  are  more  easily  catheterized  by  the  direct  cystoscope. 

This  instrument  combines  these  two  important  principles.  The  straight, 
hollow  shaft  with  a  curved  beak  can  hold  either  the  indirect  or  direct  telescopes 
(i^o.  1).  When  the  indirect  telescope  is  introduced,  the  solid  beveled  end 
of  the  telescope  fills  the  opening  in  the  end  or  convexity  of  the  shaft  and  they 
enter  in  the  same  way  as  the  former  shafts  did  with  the  solid  ends.  At  the 
same  time,  the  mirror  near  the  end  of  the  indirect  telescope  fits  into  the  window 
near  the  convexity,  on  the  straight  part  of  the  shaft,  in  such  a  way  that  a  most 
satisfactory  indirect  examination  can  be  made. 

Having  thorougldy  examined  the  bladder,  the  indirect  telescope  (Xo.  2) 
is  withdrawn  and  the  direct  telescope  (Xo.  4)  containing  the  catheters  is  in- 
troduced into  the  shaft  (xvTo.  1)  and  its  end  protrudes  from  the  opening  in  the 
end  of  the  shaft.  The  ureters  are  then  catheterized.  No.  3,  the  direct- 
observation  telescope,  is  only  used  in  teaching  the  student  to  find  the  ureters. 

There  is  an  irrigating  apparatus  connected  with  the  shaft  (Xo.  1),  into 
which  the  direct  telescope  has  been  introduced.  The  bladder  can  consequently 
be  washed  clean,  examined  thoroughly  and  the  ureters  catheterized  without 
removing  the  outer  part  of  the  instrument. 


210  CYSTOSCOPY 

The  bladder  can  be  waslK^l  out  tlii-(Mii!,li  I  lie  sliaft  (jf  tlie  instnniicnt  b_v  al- 
lowing the  solution  to  run  through  the  opening  in  one  of  the  posts  when  neither 
the  direct  nor  indirect  telescope  is  inserted,  or  through  the  same  opening  when 
the  direct  telescope  is  in  place. 

TECHNIQUE    OF   CYSTOSCOPY 

The  following  practical  part  of  this  chapter  has  been  the  result  of  experience 
gained  in  twenty  years  of  cystoscopy.  The  work  was  principally  done  in  the 
Post-Graduate,  Columbus  and  City  hospitals.  In  my  clinic  at  the  Post-Gradu- 
ate, w^e  have  done  over  3,000  cystoscopies  and  ureteral  catheterizations. 

The  following  instruments  and  apparatus  are  required  in  cystoscopy : 

( 1 )  Cystoscope. 

(2)  Table  with  knee  or  leg  rests. 

(3)  Battery;  or,  if  street  current  is  used,  a  controller. 

(4)  Soft-rubber  and  woven  coude  catheters,  Nos.  12  to  16  French  scale. 

(5)  Piston  syringe,  holding  six  ounces;  or  a  fountain  syringe. 

(6)  Ultzmann  syringe  for  injecting  cocain. 

(7)  Antiseptics:  Bichlorid  solution,  1:2,000;  silver  solution,  1:4,000; 
boric-acid  solution,  1 :  30. 

(8)  Cocain  solution,  1:100. 

(9)  Glycerin  as  a  lubricant. 

(10)  Test  glass. 

(11)  Douche  pan  or  Kelly  pad  to  catch  fluid. 

(12)  Slop  jar  at  foot  of  table. 

For  sterilization  of  the  cystoscope,  catheters  and  above  apparatus,  see  the 
chapter  on  Asepsis  and  Antisepsis.  The  cystoscope  should  never  be  boiled 
or  j^laced  in  hot  water.  It  may  be  sterilized  in  an  emergency  by  placing 
it  for  fifteen  minutes  in  a  two-per-cent  solution  of  formalin.  This  solution  we 
prepare  by  adding  two  drachms  of  our  stock  office  solution,  called  Tlolzien's 
solution-,  to  one  pint  of  water.  (Holzien's  solution  is  composed  of  formalin, 
sixty  parts,  and  alcohol,  forty  parts.)  Cystoscopes  in  the  office  are  always  kept 
sterilized  and  ready  for  use.  After  using  them,  they  are  cleaned  on  the  outside 
with  soap  and  water  and  then  alcohol,  wrapped  in  gauze  and  placed  in  Schering- 
Glatz  formalin  sterilizer  for  ten  minutes  and  allowed  to  remain  in  the  gauze 
until  the  next  examination. 

The  catheters  used  for  washing  out  the  bladder  should  have  been  previously 
sterilized.  This  is  done  by  boiling  the  rubber  ones,  while  the  woven  ones  are 
sterilized  in  the  same  manner  as  the  cystoscopes.  The  author  keeps  the  rubber 
catheters  in  a  muslin  bag,  in  which  they  have  been  boiled,  while  the  woven  cathe- 
ters are  kept  wrapped  in  the  gauze  in  which  they  have  been  sterilized. 


TECHNIQUE    OF    CYSTOSCOPY 


211 


Just  ])ri(>r  to  the  exiiiiiiiiatioii,  all  iiistrnnicnts  should  be  laid  out  on  a  sterile 
towel,  where  they  will  be  within  easy  reach  of  the  examiner.  Before  doing  a 
cystoscopy,  the  instrument  and  the  light  should  always  be  tested  to  see  if  they 
work  properly  and  to  determine  how  much  light  will  be  necessary;  the  op- 
tical ]iart  should  be  wiped  with  alcohol  and  dried  with  gauze.  The  urethra 
should  also  be  examined  to  see  if  it  will  aduiit  the  cystoscope.  jSTothiug 
is  so  exasperating  as  to  prepare  a  patient  for  cystoscopy  and  find  that 
the  hnii])  is  burned  out  or  that  the  cystoscope  cannot  pass  through  the 
urethra. 

It  is  well  to  have  everything  in  readiness  before  the  patient  is  brought  into 
the  room.  The  table  generally  used  in  this  country  is  one  which  will  admit 
of  a  certain  position,  that  is,  the  body  part  at  an  angle  of  135°  witli  that  part 
Avliich  supports  the  thighs.  There  should  be 
supports  on  each  side,  either  upright  lithot- 
ouiy  bars  or  knee  rests. 

If  cystoscopy  is  to  be  performed  in  a 
private  house,  it  is  advisable  to  send  a  port- 
able metal  table,  w^hich  can  be  adjusted  to 
the  position  already  referred  to ;  the  appa- 
ratus referred  to  should  also  be  sent. 

The  patient,  if  a  male,  is  placed  upon 

the   table    in    a    reclining    position,    with    his       Fig.   2O6.— Portable   Table   Used    for 

head    and    shoulders    slightly    elevated     and  Cystoscopy   in  the    Clinic    and   at 

,  ,  Private  Houses. 

feet    extended.      The    clothing    is    removed 

from  the  lower  limbs,  which  are  covered  with  clean  towels,  a  sheet  or  flannel 

stockings.     The  external  genitals  are  thoroughly  washed  with  soap  and  water, 

followed  by  bichlorid  solution  1 :  2,000  as  for  an  ordinary  surgical  operation. 

The  operator  prepares  his  hands  by  scrubbing  and  immersing  them  in  bichlorid 

solution. 

In  the  case  of  a  female  patient,  she  is  immediately  placed  in  the  gynecolog- 
ical position,  with  her  feet  on  the  sides  of  the  upriglit  lithotomy  bars,  or  else  her 
legs  are  supported  by  knee  rests. 

Washing  the  Bladder. — The  first  step  is  to  determine  the  bladder  capacity 
by  the  amount  of  urine  voided,  plus  the  amount  of  residual  present;  or  else  by 
measuring  the  entire  amount  of  fluid  that  can  be  tolerated  when  injected  into 
the  empty  bladder.  A  solution  of  boric  acid,  in  the  strength  of  one  part  of  boric 
acid  to  thirty  of  water,  is  used  for  washing  out  the  bladder.  In  cystoscopic 
Avork  I  usually  have  small  packages  consisting  of  half  an  ounce  of  boric  acid 
wrapped  in  a  piece  of  sterile  gauze,  and  in  making  my  solution  I  put  one  of 
these  into  a  pint  of  hot  water,  or  two  into  a  quart.  The  solution  is  injected 
through  the  outer  cylinder  of  the  cystoscope  from  a  fountain  syringe,  after 
removing  the  indirect  telescope,  or  through  a  catheter  from  a  six-ounce  piston 


212  CYSTOSCOPY 

syringe,  until  the  patient's  bladder  begins  to  feel  full.  This  marks  the  subjec- 
tive capacity  of  the  bladder  in  a  given  case,  and  the  amount  so  injected  should 
be  noted  for  future  reference.  The  more  fluid  a  bladder  holds,  the  more  easily 
it  can  be  examined. 

When  the  bladder  feels  full,  the  fluid  is  allowed  to  escape  into  the  test 
glass,  its  clearness  or  turbidity  is  noted  and  a  fresh  quantity  is  injected  into 
the  bladder  until  the  viscus  is  filled.  This  is  repeated  until  the  boric-acid 
solution  flows  into  the  test  glass  perfectly  clear.  At  times,  this  is  not  possiljle 
Avhen  there  is  much  pus  in  the  bladder ;  in  such  cases,  we  wash  until  we  get  as 
clear  a  washing  as  possible,  and  then  hasten  the  examination  for  fear  the  blad- 
der fluid  will  become  clouded  again  before  we  see  its  interior.  I  have  fre- 
quently washed  out  a  bladder  for  an  hour  and  a  half  without  obtaining  a  fluid 
medium  sufficiently  clear  for  an  examination.  This  usually  occurs  in  cases  of 
I^us  kidney  or  sacculated  bladder. 

The.  test  glass  is  a  small  glass  such  as  is  used  for  mineral  water,  or  else  an 
ordinary  tumbler. 

Filling  the  Bladder. — When  the  washing  of  the  bladder  results  in  the  dis- 
charge of  a  clear  fluid  through  the  catheter,  the  organ  is  filled  with  as  much 
fluid  as  can  be  introduced  without  causing  hematuria.  The  desired  amount  of 
distention  for  cystoscopy  is  150  to  200  c.c.  (5  to  6  oz.)  of  fluid  in  male  cases, 
and  200  to  300  c.c.  (6  to  10  oz.)  in  female. 

Introducing  the  Cystoscope. — The  instrument,  having  been  well  lubricated 
with  glycerin,  is  then  passed  into  the  bladder,  practically  the  same  tech- 
nique being  used  as  in  introducing  metallic  sounds.  Very  often  the  in- 
strument glides  into  the  urethra  down  to  the  cut-off  muscle,  where  it  meets 
resistance,  due  to  a  certain  amount  of  spasm  which  takes  place  if  the  posterior 
urethra  is  involved  and  tender.  The  cystoscopist  must  not  attempt  to  push  the 
cystoscope  through  this  muscle,  for  if  he  does  it  may  be  attended  by  a  certain 
amoimt  of  hemorrhage  which  would  blur  the  vision;  therefore,  he  should  hold 
the  instrument  against  the  muscle,  exerting  gentle  pressure,  and  soon  it  will 
be  felt  to  relax  and  the  instrument  will  glide  through  into  the  posterior  urethra 
and  then  through  the  sphincter  into  the  bladder.  Sometimes,  however,  it  is  not 
the  cut-off  which  resists,  but  the  vesical  sphincter,  in  which  case  the  same  tac- 
tics are  pursued  and  the  cystoscope  passes  the  rebellious  sphincter  and  enters 
the  viscus.  A  small  amount  of  two-per-cent  cocain,  injected  by  means  of  an 
Ultzmann  syringe  or  through  a  very  fine  catheter  into  the  posterior  urethra  and 
the  neck  of  the  bladder  just  before  the  final  filling,  will  prevent  the  spasm.  This 
is  usually  caused  by  an  inflammatory  condition  beyond  the  cut-off  muscle  or  the 
bladder  sphincter,  which  sensitive  areas  these  muscles  try  to  protect  through 
their  contraction. 

Changing  the  Patient's  Position.— The  foot  board  of  the  table  is  then  low- 
ered to  the  full  extent,  and  the  patient,  if  a  male,  has  his  legs  supported  in 


TECI-miQUE    OF    CYSTOSCOPY 


213 


lithotomy  iipriglits,  or  kiieo  rests  (Fig.  207),  after  Avliicli  liis  buttocks  are 
brought  to  within  six  inches  of  the  edge  of  the  talAe,  the  surgeon  meanwhile 
keeping  the  cystoscope  in  place  by  a  gentle  grasp  upon  the  handle  of  the  in- 


FiG.  207. — The  Patient's  Legs  Supported  by  Knee  Rests,  and  the  Seat  Portion  of  the  Table 
SLIGHTLY  Elevated,  the  Position  usually  Employed  in  the  Office.  The  table  is  the  Alli- 
son model. 


striiment.  In  the  case  of  a  female  patient,  she  is  already  in  such  a  position 
from  the  first,  and,  therefore,  does  not  require  to  have  it  changed.  The  patient's 
hips  may  be  slightly  elevated,  as  this  helps  the  cystoscopist  to  examine  the 
bladder  more  easily. 

Should  the  bladder  contents  become  too  cloudy  before  the  examination  is 
completed,  the  cystoscope,  in  case  it  is  a  simple  observation  cystoscope,  should 
be  withdrawn,  the  bladder  once  more  washed,  filled  with  clear  fluid  and  the 
instrument  reintroduced. 

The  irrigating  cystoscope  has  an  arrangement  for  washing  the  bladder  while 
the  instrument  is  in  place.  In  order  to  do  this,  there  must  be  a  small  piece  of 
rubber  tubing  on  the  nozzle  of  the  irrigating  opening,  and  water  should  be 
forced  into  this  through  a  piston  syringe.  This  not  only  cleanses  the  bladder 
wall,  but  also  the  Avindow  of  the  instrument  and  thus  washes  away  any  deposits 
of  blood,  mucus  or  pus,  that  may  have  collected  there.  The  fluid  escapes  from 
a  nozzle  on  the  other  side  of  the  instrument.  Thus  a  thorough  lavage  of  the 
bladder  can  be  made.  In  my  own  cystoscope,  the  lavage  can  be  made  through 
an  irrigating  apparatus  by  connecting  the  tube  from  a  fountain  syringe  with 
the  nozzle  and  allowing;  the  solution  to  run  into  the  bladder  and.  Qii.t  of  the  hoi- 


214 


CYSTOSCOPY 


low  shaft  (Figs.  208,  209).  The  quickest  way  to  cleanse  the  bladder  is  tlirouiih 
the  shaft  of  the  instrument,  as  a  larger  quantity  of  solution 
can  quickly  run  in  and  out  again. 

The  Light. — The  power  for  the  light  is  taken  either  from 
the  street  current  by  means  of  a  Wappler  electric  controller, 

or  else  from  a  storage  battery  on  the 
left  side  of  the  patient.  One  end  of 
the  cable  is  then  connected  with  the 
cystoscope  and  the  other  with  the 
electric  controller  or  the  storage  bat- 
tery, after  which  the  operator  turns 
on  the  current  by  means  of  a  switch 
or  screw  in  the  handle  of  the  cysto- 
scope. And  here  the  technique  dif- 
fers according  to  whether  a  direct 
or  indirect  instrument  is  being 
used. 

If  the  instrument  is  indirect,  as 
in  the  observation  part  of  my  own 
cystoscope,  turning  on  the  current  is 
sufficient  to  allow  the  cystoscopist  to 
examine  the  bladder ;  whereas,  in  di- 
rect cystoscopes  of  American  make, 
it  is  necessary  to  withdraw  the  ob- 

FiG.  208. — Washing  Out  the  Bladder.     The  wa-  turator,     place     the     tlinmb     quicklv 

ter   is   running    in    from    the    fountain    syringe  ,                    .              j?     ;i           i      r-.       \c 

through  a  tube  attached  to  the  irrigating  nozzle  O^er     the     Opening     of     the     shaft     0± 

of  the  instrument;  the  thumb  is  held  over  the  end  the     instrument     to     prevent     the     es- 

of  the  hollow  shaft.     The  force  of  the  fluid  can  be  £      'i         -Q     '  ^            11 

changed  by  raising  or  lowering  the  irrigating  jar.  Cape     01     tiie    nUlU     ailU     tlieil     llltrO- 


FiG.  209. — Washing  Out  the  Bladder.  The  bladder  has  been  dilated  to  its  point  of  tolerance  (see 
dotted  lines),  the  thumb  has  been  removed  from  the  end  of  the  shaft  and  the  fluid  rushes  out 
through  its  lumen,  the  bladder  quickly  emptying. 


TECHNIQUE    OF    CYSTOSCOPY 


215 


Fig.  210. — Looking  into  the  Bladdeb. 
The  patient's  feet  are  in  lithotomy  upright,  the  position  usually  used  in  the  clinic. 


Fig.  211.— AirCystoscope.     Patient  in  partial  Trendelenburg  position.     Bladder  being  inflated  with 
air  from  tank  on  the  table.     (From  Luys.) 


216  CYSTOSCOPY 

duce  tlie  telescope  before  the  interior  of  tlie  l)la(l(ler  can  he  examined  l)y  the 
cjstoscopist. 

In  either  case,  after  the  instrument  lias  liecn  introduced  and  everything  is 
in  readiness  for  examination  and  the  cable  connection  is  made,  the  examiner  sits 
between  the  legs  of  the  patient  and  turns  on  tlie  power  until  the  light  is  suffi- 
ciently bright  for  him  to  see  plainly  the  interior  of  the  bladder,  before  pro- 
ceeding to  examine  it  (Fig.  210).  The  storage  battery,  freshly  recharged  at 
regular  intervals,  is  generally  used  for  outside  work  in  private  houses  and  in  the 
office  or  in  hospitals,  unless  electric  illumination  is  present,  in  which  case  a 
controller  is  preferable. 

The  position  of  the  patient  with  air  cystoscopy  is  different  as,  in  this  case, 
the  patient  is  in  a  partial  Trendelenburg  position  which  allows  the  bladder  to 
balloon  out  to  better  advantage  and  the  urine  coming  from  the  ureter  to  gravi- 
tate toward  the  apex  of  the  bladder  and  away  from  the  instrument  (Fig.  211). 

DIFFICULTIES   IN   CYSTOSCOPY 

Stricture  of  the  Urethra. — The  first  difficulty  encountered  in  cystoscopy  is 
organic  stricture  of  the  urethra.  Very  few  cystoscopes  that  give  a  good  view  of 
the  bladder  are  less  than  No.  2-1  of  the  French  scale  in  size.  Therefore,  the 
urethra  should  be  g/:  least  25  French  in  caliber,  in  order  to  allow  free  admission 
of  the  cystoscope  without  causing  traumatism  or  hemorrhage.  If  the  meatus 
is  smaller  than  this  number,  it  should  be  cut  up  to  28  or  30  French  and  should 
be  treated  as  any  other  case  of  meatotomy  for  a  few  days,  until  it  has  healed 
to  a  larger  size,  sufficient  to  admit  the  instrument  easily. 

If  there  are  strictures  along  the  canal,  they  should  be  dilated,  if  soft  and 
dilatable ;  if  not,  they  should  be  cut  to  a  sufficient  size  to  admit  the  instrument 
before  cystoscopy  is  performed. 

Spasmodic  strictures  are  also  common,  but  they  usually  yield  to  instilla- 
tions of  a  two-per-cent  solution  of  cocain,  given  through  a  small  catheter,  or  by 
means  of  an  Ultzmann  syringe.  In  case,  however,  that  local  cocain  anesthesia  is 
not  sufficient,  a  general  anesthetic  should  be  administered,  preferably  nitrous- 
oxid  gas  alone  or  followed  by  ether. 

An  enlarged  prostate  that  bleeds  easily  should  be  treated  by  a  deep  urethral 
instillation  composed  of  equal  parts  of  a  two-per-cent  solution  of  cocain  and  a 
1 :  1,000  solution  of  adrenalin. 

Pelvic  exudates,  uterine  displacement  and  pelvic  tumors,  of  sufficient  size 
to  interfere  with  the  function  of  the  bladder  and  to  make  cystoscopy  difficult, 
are  of  enough  importance  to  call  for  a  vaginal  operation  in  the  first  instance  and 
an  abdominal  operation  for  the  other  two  conditions. 

Small,  Intolerant  and  Sensitive  Bladders.^Sometimes  a  few  irrigations 
of  the  bladder  will  dilate  it  sufficiently  to  allow  of  a  satisfactory  cystoscopy,  for 


DIFFICULTIES    IN    CYSTOSCOPY  217 

which  150  to  200  t'.c.  (5  to  (5  oz.)  is  usually  necessary.  Examinations  oan,  how- 
ever, he  made  with  two  ounces  of  fluid  in  the  bladder,  and  I  have  made  them  with 
hut  one  ftunce  and  a  half,  by  means  of  an  indirect  instrument.  In  case  a  bladder 
is  very  sensitive,  cocain  or  a  general  anesthetic  should  be  used,  as  many  blad- 
ders that  will  hold  but  from  one  to  two  ounces  under  other  circumstances 
will,  Avhen  anesthetized  locally  or  generally,  retain  four  ounces  or  more. 
Twenty  grains  of  antipyrin  and  ten  minims  of  laudanum  in  an  ounce  of  water, 
injected  into  the  rectum  forty-five  minutes  before  cystoscopy,  will  often  relieve 
the  patient  sufficiently  to  permit  a  cystoscopic  examination. 

If  tlie  bladder  is  found  intolerant  and  will  not  hold  enough  fluid,  it  should 
be  emptied  and  half  an  ounce  of  a  one-per-cent  solution  of  cocain,  or  a  two-per- 
cent solution  of  eucain,  should  be  injected  into  the  bladder  through  a  catheter. 
Chismore,  of  San  Francisco,  in  doing  lithotomy  in  old  men,  used  to  inject  two 
or  three  ounces  of  a  three-per-cent  solution  of  cocain  into  the  bladder  as  a  mat- 
ter of  routine,  with  no  ill  effects.  Surgeons  differ  so  much  as  to  the  strength  of 
cocain  used,  that  it  is  really  a  matter  of  individual  experience.  In  the  ordinary 
case,  ten  one-half -grain  cocain  tablets  in  two  ounces  of  water,  making  a  one-half- 
per-cent  solution,  is  sufficiently  strong  for  cystoscopic  use.  In  cases  of  severe 
tubercular  cystitis,  a  solution  of  the  maximum  strength  cannot  be  relied  on. 

If  cocain  does  not  produce  sufficient  anesthesia,  nitrous-oxid  gas  should  be 
used  during  the  introduction  of  the  instrument;  and  if  anesthesia  has  to  be 
continued,  ether  should  be  administered. 

Distention  Hematuria. — Under  ether,  patients  are  supposed  to  hold  more 
fluid  in  the  bladder  than  when  examined  without  anesthetics.  If,  under  anes- 
thesia, the  bladder  holds  two  ounces  and  you  try  to  insert  three  for  cystoscopy, 
you  may  have  a. pinkish  discoloration  of  the  fluid,  due  to  the  bladder  wall  being 
stretched  and  some  capillary  leakage  resulting,  or  else  bleeding  from  ulcera- 
tions, tumors  or  erosions.  Such  bladders  can  often  be  dilated,  under  anesthetics, 
better  by  means  of  the  fountain  syringe  than  by  the  piston  variety.  In  this 
way,  after  a  quarter  of  an  hour  of  washing,  during  which  time  the  hematuria 
may  increase  somewhat,  perhaps  five  ounces  can  be  introduced  into  the  bladder. 
In  these  cases,  the  time  that  it  takes  for  this  amount  of  fluid  to  enter  should 
be  noted,  and  at  the  next  filling  a  certain  number  of  seconds  under  this  time 
should  be  allowed  the  fluid  to  run  in,  to  see  if  hematuria  is  caused.  If  hema- 
turia is  caused,  then,  the  next  time  the  bladder  is  filled,  allow  still  less  time  for 
its  filling;  and  so  on  until  a  point  is  reached  where,  in  a  certain  time,  the 
amount  of  water  entering  the  bladder  is  not  sufficient  to  cause  a  pink  discolora- 
tion of  the  fluid.  On  the  following  injection  of  the  bladder,  if  five  seconds  less 
are  allowed,  you  will  be  sure  to  have  a  clear  fluid  for  cystoscopy. 

To  make  this  clear,  I  will  cite  one  or  two  cases.  A  patient  with  a  cystitis 
dependent  upon  a  hypertrophied  prostate  had  a  maximum  bladder  capacity  of 
two  ounces  of  urine.     Under  an  anesthetic,  his  bladder  held  three  ounces.     The 


218  CYSTOSCOPY 

three  ounces  ran  in  tlirouoh  flic  catlictcr  in  forty-five  seconds.  The  next  time, 
fluid  was  allowed  to  run  in  for  one  minute;  four  ounces  were  then  introduced, 
whicli  in  escaping  was  found  to  be  tinged  with  blood,  being  slightly  pink  in 
color.  At  the  next  filling  of  the  bladder,  a  minute  and  a  quarter  was  allowed 
and  five  ounces  entered.  The  escaping  fluid  was  tlien  of  a  more  reddish  color. 
The  next  time  it  was  allowed  to  run  in  for  about  a  minute  and  a  half,  and  six 
ounces  entered.  This  on  escaping  was  no  more  bloody  than  wlien  the  five  ounces 
had  been  injected.  The  next  time  four  ounces  were  put  in  in  one  minute  and 
the  fluid  was  clear.  Five  ounces  were  again  put  in,  which  showed  on  escaping 
a  pinkish  tinge,  but  not  as  marked  as  before.  It  was  then  felt  that  a  little  under 
four  ounces  would  be  the  sure  capacity  of  the  bladder  for  cystoscopy  without 
hcnuituria  while  Tni(U'r  an  anesthetic.  This  was  accordingly  carried  out  by 
allowing  the  fluid  to  run  in  for  fifty-five  seconds. 

Another  patient  with  tuberculosis  of  the  bladder  could  hold  but  an  ounce 
and  a  half  of  fluid  when  his  bladder  was  washed  out.  Under  an  anesthetic  two 
ounces  entered  in  half  a  minute,  producing  no  hematuria.  Three  ounces  entered 
in  forty-five  seconds,  producing  hematuria.  On  introducing  two  ounces  again, 
there  was  no  hematuria.  Several  trials  were  made  with  three  ounces  both 
through  fountain  and  piston  syringe,  and  each  produced  hematuria.  It  was 
found  that  two  and  one  half  ounces  could  be  put  in  the  bladder  in  thirty-eight 
seconds  without  making  the  urine  bloody.  The  cystoscopic  examination  was 
then  made  with  this  amount  in  the  bladder.  It  must  always  be  remembered  that 
a  very  sensitive  bladder,  particularly  in  tuberculosis,  will  not  dilate  to  its  full 
capacity,  even  under  general  anesthesia,  unless  it  is  pushed  to  a  point  at  whicli 
it  is  dangerous  to  life.     Ether  is  the  best  general  anesthetic  to  use. 

NORMAL  AND  PATHOLOGICAL  FINDINGS  WITH  THE    CYSTOSCOPE 

After  the  cystoscope  has  been  introduced  and  the  light  has  been  turned  on, 
it  is  always  advisable  to  pursue  a  certain  routine  in  the  order  of  examination, 
so  that  one  may  not  miss  any  part  of  the  bladder  in  the  survey  and  yet  may  per- 
form the  examination  with  as  few  movements  of  the  instrument  as  possible. 

We  will  now  speak  of  the  indirect  cystoscopes  used  for  observation  which  are 
the  best  for  diagnostic  purposes.  As  the  field  of  the  cystoscope  is  limited,  we 
must  form  a  picture  of  the  entire  interior  of  the  bladder  by  means  of  a  series 
of  partial  pictures  which  should  so  follow  each  other  as  the  instrument  moves 
that  we  gain  a  very  accurate  knowledge  of  the  entire  organ.  The  rules  that 
Nitze  gave  for  this  purpose  may  be  set  down  here  for  reference,  although  each 
observer  will  necessarily  vary  his  method  somewhat,  according  to  his  own  prac- 
tical experience. 

Nitze  advised  that  the  anterior  and  upper  portions  of  the  bladder  be  in- 
spected first  and  the  fundus  and  trigone  last.     After  the  cystoscope  has  been  in- 


FINDINGS    WITH    THE    CYSTOSCOPE 


219 


trnducod,   Avitli  tlie  mirror  ])oiiiliiin-  upward   and   the   iiistriiiiient   parallel  with 
the  tahle,  its  beak  is  turned  at  an  angle  of  22.5°  toward  the  right  side  of  the 
j^atient  and  the  instrument  is  now 
passed  slowly  backward  until  the 
beak    touches    the    posterior    wall. 
The  field  of  the  cjstoscope   thus 
sweeps  over  a  section  of  the  an- 
terior   and    upper    vault    of    the 
bladder,    and    covers    part   of    the 
posterior  wall.      The  strip  of  the 
illuminated    bladder    corresponds 
in  width  to  the  angle  of  the  prism 
which    defines    the    width    of    the 
field.     As  soon  as  the  beak  touches 
the    posterior   wall,    it   is 
turned  still  farther  to  the 
right  (i.  e.,  at  an  angle  of 
45°     from     the     median 
line),    and   is   swept   for- 


FiG.   212. — The  Cystoscope   Introduced 
INTO  THE  Bladder. 


ward,  illuminating  a  strip  paral- 
lel to  the  first,  but  lying  to  the 
right  of  the  latter,  sweeping  the 
beak  from  behind  forward  and 
thus  covering  the  right  lateral 
portion  of  the  bladder.  ISText  the 
left  half  of  the  bladder  is  in- 
spected. This  is  done  by  placing 
the  instrument  again  in  the  me- 
dian line  with  the  beak  at  the 
internal  opening  and  turning  it 
22.5°  to  the  patient's  left,  sweep- 
ing it  slowly  from  before  back- 
Avard  in  this  position  until  it 
touches  the  posterior  wall ;  then 
turning  it  to  45°,  i.  e.,  still  more 
to  the  patient's  left,  and  sweep- 
ing it  from  behind  forward,  thus 
covering  the  two  zones  lying  to 


Fig.  212a. — Inspection  of  the  Bladder  with  the 
Indirect  Cystoscope.  The  excursion  made  on  the 
right  side  of  the  bladder  at  an  angle  of  22.5°  from 
the  median  line  of  the  bladder,  aA,  and  the  excursion 
made  at  an  angle  of  45°,  Dd.  hB  and  Cc  show  similar 
excursions  on  the  left  side  of  the  bladder.  The  cysto- 
scope turned  down  in  a  similar  position  would  easily 
show  the  trigone.     (From  Morrow,  after  Nitze.) 


220 


CYSTOSCOPY 


the  left  of  the  nicdian  line.  With  tliese  four  motions,  two  to  the  h'ft  and  two 
to  the  right,  practically  the  entire  upper  and  lateral  j)ortion.s  of  the  lihiddcr  are 
inspected  {Fig.  212«). 

There  remains  to  be  seen  now  the  fundus  and  the  neighborhood  of  the  in- 
ternal meatus.  For  this  purpose  the  instrument  is  turned  so  that  the  beak  points 
directly  downward  and  is  swept  from  side  to  side  from  behind  forward,  or  from 
before  backward,  until  every  portion  of  the  posterior  wall  of  the  bladder  and  the 

trigone  has  been  covered. 
It  is  needless  to  say  tliat  all 
these  manipulations  must 
be  gentle  to  avoid  injuring 
the  bladder  wall.  Burning 
the  bladder  woidd  not  be 
liable  to  occur  with  the  cold 
lamp  now  generally  used 
in  this  country,  although  it 
was  common  when  the  hot 
lamp  was  in  use. 

The  direct  cystoscope  is 
not  so  good  for  observation 
purposes.  It  is  introduced 
with  its  obturator,  Avhich 
is  then  withdrawn  and  the 
direct  telescope  inserted. 
It  is  then  pushed  well  back 
into  the  bladder  and  its 
beak  is  tilted  up  and 
swept  from  side  to  side,  in 
this  way  showing  some  of 
the  roof  of  the  bladder 
with  the  adjoining  part  of 
the  anterior  wall ;  the  lat- 
eral and  posterior  walls 
are  then  examined  and  the 
instrument  is  drawn  for- 
ward until  the  interure- 
teral  band  and  the  trigone 
are  seen.  This  applies  to  direct-air  or  water  cystoscopes,  while  another  telescope, 
made  by  Wappler,  with  an  opening  in  the  side  near  the  end,  allows  us  to  look 
back  at  an  acute  angle  at  the  neck  of  the  bladder  and  the  prostatic  base. 

Normal  Cystoscopic  Pictures. — It  is  necessary  for  the  practitioner  to  be 
familiar  with  the  appearance  of  the  normal  bladder  before  he  can  understand 


Fig.  2126. — Inspection  of  the  Bladder  with  the  Direct 
Cystoscope.  The  beak  of  the  direct  cystoscope  is  moved 
from  right  to  left  and  vice  versa  in  examining  the  floor  and  roof 
of  the  bladder,  and  from  above  downward  in  examining  its 
sides. 


FINDINGS    WTTTT    THE    CYSTOSCOPE  221 

tlio  coiulitions  seen  in  a  pathological  organ.  The  interior  of  I  he  Madder  as  illii- 
ininated  by  the  cystoscope  has  a  pale-yellow,  orange  or  a  pink  tinge,  depending 
for  its  exact  color  upon  the  lamp  and  prism  used.  A  number  of  branching  blood 
vessels  are  seen  outlined  upon  it  in  darker  red,  which  in  healthy  bladders  are 
clear-cut  and  finely  drawn.  The  upper  hemisphere  of  the  healtliy  bla<ldcr  wall 
is  smooth,  but  as  the  cystoscope  is  drawn  over  the  posterior  wall  toward  the  neck 
of  the  bladder  at  its  base,  a  thickened,  slightly  redder  portion  is  brought  into 
view,  triangular  in  shape  and  tapering  toward  the  vesical  neck,  where  it  ends 
in  a  dark-red  color.  This  triangular  space,  with  sides  an  inch  and  a  quarter  to 
an  inch  and  a  half  long,  is  called  the  trigone.  Its  apex  corresponds  to  the  in- 
ternal meatus,  and  its  base  to  the  interureteral  band.  The  apex  is  on  the  base 
of  the  prostate  in  men,  which  is  a  dull  red,  or  crimson,  color.  The  female  blad- 
der differs  from  the  male  principally  in  not  showing  so  much  thickening  about 
the  internal  meatus,  nor  such  a  well-marked  trigone.  The  base  of  the  trigone 
sweeps  from  one  ureteral  opening  to  the  other  and  disappears  in  the  wall  of  the 
bladder  beyond  these  openings,  where  the  color  changes  to  an  orange  shade. 
On  either  side  of  the  trigone  is  the  paratrigonal  fossa. 

The  Finding  of  the  Ureteral  Orifices. — The  next  step  is  the  most 
important  of  the  whole  procedure,  namely,  the  finding  of  the  ureteral  mouths. 
With  the  direct  instrument,  it  is  more  difficult  to  inspect  the  bladder  walls  and 
consequently  the  position  of  the  instrument  must  be  changed  considerably  to 
accomplish  this.  The  instrument  in  the  bladder,  with  the  direct  telescope  in- 
serted, should  be  pushed  back  slowly,  in  the  median  line,  illuminating  the 
trigone  until  the  interureteral  fold  is  brought  into  view.  The  end  of  the  cys- 
toscope is  then  turned  from  the  right  to  the  left,  following  the  interureteral 
band,  until  an  angle  from  30°  to  40°  from  the  perpendicular  is  reached, 
when  the  ureteral  orifice  will  usually  be  brought  into  view.  This  is  the  theo- 
retical procedure,  but  practically  the  exact  modus  operandi  must  be  varied  to 
a  marked  extent,  according  to  the  condition  of  the  ureters,  which  varies  normally 
to  a  considerable  degree  according  to  various  peculiarities  of  the  bladder  of  the 
individual  examined. 

The  Appearance  of  the  Ureteral  Orifices. — The  ureteral  openings  are 
at  the  two  posterior  angles  of  the  trigone  and  present  in  most  bladders  the  shape 
of  a  slightly  oblique,  dark-red  slit,  or  a  more  rounded  depression,  and  are  situ- 
ated ujion  a  more  or  less  marked  papilla  or  prominence.  With  the  indirect 
cystoscope  and  the  patient  in  the  cyst.oscopic  position,  if  the  beak  is  turned 
downward,  the  part  of  the  bladder  before  us  will  be  the  base,  the  interureteral 
band  and  the  ureters. 

Difficulty  in  finding  the  ureter  in  a  healthy  bladder  depends  usually  on  an 
insufficient  amount  of  fluid  and  the  consequent  folding  in  of  the  uuicous  mem- 
brane in  places.  The  introduction  of  an  additional  amount  of  water  through 
the  irrigating  ajjparatus,  b}'  dilating  the  entire  wall,  will  stretch  out  these  folds 


222  CYSTOSCOPY 

and  bring'  the  iirctors  into  view.  This  is  liest  aeconiplisliod  as  follows:  The  irri- 
gating nozzle  of  the  eystoscope  is  connected  with  the  tube  of  a  fountain  syringe, 
or  the  tip  of  a  large  piston  syringe  is  inserted  into  a  small  piece  of  tubing  at- 
tached to  the  irrigating  nozzle,  and  the  fluid  slowly  injected,  while  at  the  same 
time  the  base  of  the  trigone  is  carefully  watche<l.  This  portion  of  the  bladder  is 
sometimes  out  of  position ;  in  men,  usually  due  to  prostatic  involvement,  and 
in  women,  due  to  cystocele.  In  such  cases,  the  finger,  a  rectal  bag  or  a  vaginal 
depressor  inserted  into  the  rectum  will  serve  to  push  it  to  a  better  position. 

Having  found  the  ureters,  it  is  well  to  examine  them  carefully,  not  only  for 
the  sake  of  learning  their  shape  and  locality,  but  also  to  note  any  abnormalities 
connected  with  them  or  the  urine  they  emit. 

The  ureteral  mouths  are  sometimes  so  dilated  as  to  resemble  diverticula', 
and  I  have  at  times  been  able  in  this  condition,  after  a  perineal  urethrotomy, 
to  insert  the  tip  of  my  forefinger  into  the  mouth  of  each  ureter. 

If  a  ureteral  mouth  is  prolapsed,  it  reminds  us  that  there  may  be  some  in- 
flammation of  it,  or,  more  probable,  that  a  calculus  is  present  in  the  ureter  near 
the  oj)ening  into  the  bladder,  not  perhaps  of  the  correct  shape  to  absolutely 
occlude  the  ureter,  but  sufficient  to  give  rise  to  ureteral  strain  and  a  consequent 
protrusion  of  its  walls.  Sometimes  a  stone  can  be  seen  protruding  into  the 
bladder,  as  a  dark  spot  in  a  gaping  ureter. 

If  the  ureteral  openings  be  watched  for  a  time  every  thirty  to  sixty  seconds, 
the  slit  may  be  seen  to  dilate  suddenly,  to  take  on  a  transparent  pink-orange 
hue  and  a  wliirl  of  fluid  of  an  oily  appearance  is  seen  streaming  from  it  as  the 
result  of  the  expulsion  of  the  urine  from  the  ureters.  These  spurts  are  not 
synchronous. 

In  disease,  the  ureteral  opening  is  often  markedly  altered  and  blood  and 
-pus  may  be  seen  coming  from  it.  Blood  coming  from  the  ureters  is  almost  al- 
ways renal,  although  it  may  be  ureteral.  It  usually  comes  down  mixed  with 
the  urine  and  is  often  squirted  out  like  a  thin  stream  of  red  ink,  although  clots, 
of  a  wormlike  appearance,  may  descend.  Pus  comes  down  in  flakes  and  is  car- 
ried away  in  the  swirl  and  then  seen  to  scatter  and  fall  in  tlie  bladder,  or  else  a 
flake  may  catch  in  the  ureteral  mouth  and  be  thrown  out  with  the  next  swirl ; 
or  it  may  come  down  from  a  ureter  as  a  thick  mass  and  remain  hanging  in  the 
bladder  at  the  ureteral  mouth,  or  mixed  with  urine  giving  it  a  milklike  color,  or 
as  a  mealy  mixture  which  is  shot  out  in  a  urinary  swirl. 

Pathological  Findings  in  the  Bladder.— Cystoscopy  tells  us  whether  the 
ureteral  orifices  are  both  present,  their  location,  shape  and  condition,  whetlua' 
they  are  both  secreting  urine  normally,  and  whether  this  urine  is  clear,  purulent 
or  bloody.  It  also  enables  us  to  determine  whether  the  sphincteral  margin  is 
normal  or  the  seat  of  disease,  such  as  inflammation,  ulceration,  papillomatous 
formation,  etc.;  whether  the  trigone  is  normal  or  the  seat  of  inflammations  or 
new  growths;  or  whether  foreign  bodies  or  calculi,  which  occur  in  a  majority 


FINDINGS    WITH   THE    CYSTOSCOPE  223 

of  cases  in  this  reoioii,  are  present.  It  sliows  us  tlic  jn-esence  and  proLaljle  eliar- 
aeter  of  new  growths ;  the  presence  and  })osition  of  foreign  bodies  and  calcnli ; 
the  presence  of  prostatic  hypertrophy,  of  cystoeele,  the  condition  of  the  wall 
of  the  bladder  and  whether  it  is  the  seat  of  trabecular  bands  or  the  scarlike  con- 
tractions of  pericystitis;  whether  it  is  normal  or  the  seat  of  inflammations, 
points  of  hemorrhage,  ulcerations,  nodnles,  new  growths,  vesicles  or  diverticulee ; 
whether  the  cavity  of  the  bladder  is  encroached  upon  by  other  organs,  as  an 
enlarged  or  displaced  uterus  or  by  pelvic  tumor-masses  or  exudates. 

Trabecule,  Bands  and  Pouches. — When  the  bladder  is  subjected  for  a 
long  time  to  an  increased  strain,  the  muscular  wall  may  become  more  or  less 
liypertrophied,  the  result  being  that  muscular  bands  develop  in  certain  parts  of 
the  bladder,  while  other  muscular  fibers  remain  unchanged.  When  we  look  into 
such  a  bladder,  we  notice  prominent  bands  or  trabecular  crisscrossing  in  various 
directions  and  forming  an  irregular  network.  As  the  hypertrophy  goes  on,  the 
bands  become  more  and  more  markedly  developed,  resembling  the  intertwining 
of  the  roots  of  trees  in  the  woods  or  swamps,  and  the  spaces  between  them  be- 
come dark  depressions.  When  large  enough,  these  depressions  are  called  diver- 
ticulfe.  With  an  increase  of  pressure  and  with  an  atonic  condition  of  the  de- 
pressed portions,  the  latter  become  veritable  pouches,  which  sometimes  have 
such  small  mouths  that  their  interior  cannot  be  inspected.  In  fact,  in  many 
bladders  removed  at  autopsy  the  pouches  have  such  small  mouths  that  they  look 
like  distended  ureteral  orifices. 

Trabeculation  is  easily  recognized  even  by  the  beginner  and  may  be  inter- 
preted as  a  sign  of  hypertrophy  of  the  walls  due  to  some  condition  which  in- 
terferes with  the  emptying  of  the  bladder.  The  conditions  may  be  a  small 
meatus,  a  stricture  or  enlarged  prostate  in  men,  and  displacement  of  the  bladder, 
adhesions  or  pressure  on  the  outside  of  the  bladder  in  women. 

Inflammations  of  the  Bladder. — It  is  difficult  to  cystoseope  a  patient 
with  an  acute  cystitis  on  account  of  the  very  sensitive  condition  of  the  bladder. 
Inflammation  is  most  frequently  about  the  vesical  neck,  although  it  may  extend 
throughout  the  viscus.  Less  frequently  there  is  a  generalized  reddening  and  in- 
tense congestion  of  the  entire  bladder.  The  characteristic  changes  of  an  acute 
inflammation  consist  in  the  presence  of  reddened  areas  with  many  enlarged 
blood  vessels,  with  the  presence  of  pus  and  mucus — both  upon  the  walls  and  in 
the  fluid  which  becomes  rapidly  turbid — and  at  times  blood  oozing  from  the 
walls  which  quickly  renders  the  field  obscure.  When  we  make  a  closer  exam- 
ination of  the  mucosa  in  such  cases,  small  erosions,  which  have  a  dull  surface 
instead  of  the  normal  shiny  lining  of  the  wall,  and  localized  hemorrhagic  areas, 
which  appear  as  dark-red  patches,  may  be  noted. 

In  chronic  cystitis,  the  bladder  is  usually  pale  in  its  interior,  except  over  the 
trigone,  where  it  is  generally  thickened  and  reddened.  Reddened  patches  may 
also  be  noted  in  other  portions  of  the  wall,  however.     In  cases  of  long  standing, 


224  CYSTOSCOPY 

witli  liypertropliy  of  the  walls,  tliere  are  also  trabeculsp  and  pouches.  Acciimii- 
latioiis  of  pus  may  be  noted  adherini;'  to  the  walls,  or  hanjiinn'  or  waving-  in  the 
fluid  in  the  form  of  shreds.  Tha  blood  vessels  are  turgid  in  jjlaces  and  circum- 
scribed nlcerating  areas  may  also  be  seen  in  this  condition. 

In  the  early  stages  of  chronic  cystitis,  there  is  no  perceptible  change  in  the 
volume  of  the  bladder,  but  later  on  there  may  be  hypertrophy,  or  an  interstitial 
inflammatory  process  with  a  contraction  of  the  viscus ;  while  in  the  advanced 
stage  of  chronic  obstructive  cystitis,  there  may  be  a  dilatation  of  the  organ  due 
to  the  retention  of  nrine.  When  this  takes  place,  the  mouths  of  the  ureters  will 
appear  to  be  enlarged  and  distorted. 

Simple  Ulcers  of  the  Bladdek. — Simple  ulcers  may  be  either  single  or 
multiple.  If  single,  they  are  usually  large  and  accompanied  by  thickened  and 
elevated  edges  and  irregular  base  which  may  be  covered  by  a  collection  of  phos- 
phate-of-lime  salts  or  an  accumulation  of  pus.  ]\Iultiple  ulcers  are  usually 
smaller  and  less  marked.  They  are  sometimes  mistaken  for  epithelioma,  espe- 
cially when  they  are  large  and  have  a  coarse,  gTanular  base  covered  with  pus. 
They  are  generally  due  to  traumatism  and  heal,  leaving  scar  tissue. 

TuBEECULOsis  OF  THE  Bladdee. — Tubcrculosis  of  the  bladder  is  one  of  the 
most  frequent  pathological  conditions.  In  its  early  stages,  all  that  can  be  seen 
are  the  minute  lesions,  wdiite,  yellow  or  gray,  surrounded  by  a  pink  aureola. 
These  are  seen  scattered  about  the  bladder,  often  in  clusters.  Later  they  break 
down  as  tubercular  ulcers  which  are  of  different  varieties.  There  may  be  a  clus- 
ter of  small  ulcers  resembling  a  cold  sore,  but  more  infiltrated,  usually  seen 
about  the  mouth  of  a  ureter ;  or  a  local  thickening  with  fine  ulcerations  on  its 
surface ;  or  a  superficial  ulcer  resembling  an  erosion  w^ith  the  epithelia  removed, 
and  a  pink,  pulpy  surface  with  the  edges  but  slightly  marked  and  with  almost 
no  infiltration.  In  other  cases  the  bladder,  especially  the  trigone,  may  be  cov- 
ered with  small  ulcers,  the  wall  intensely  inflamed,  oozing  blood  and  contracted : 
this  is  spoken  of  as  hemorrhagic  cystitis.  In  this  last  class  of  cases,  which  are 
tubercular,  it  is  difficult  to  obtain  a  good  view  of  the  bladder,  even  under  an 
anesthetic. 

When  ulcers  are  seen  around  the  ureteral  mouths,  we  must  suspect  a  tuber- 
cular renal  affection  on  that  side,  especially  when  such  ulcers  have  some  sur- 
rounding hyperemia  and  a  base  so  uneven  as  to  make  it  difficult  to  know  which 
of  its  various  recesses  is  the  opening  into  the  ureter.  In  advanced  cases  of 
tuberculosis  of  the  bladder,  the  organ  is  so  contracted  and  sensitive  that  cystos- 
copy cannot  be  satisfactorily  performed. 

Stone  iisr  the  Bladder. — Stone  in  the  bladder  can  usually  be  recognized 
quite  readily  with  the  cystoscope.  The  appearance  of  a  stone  in  the  bladder, 
next  to  a  tumor,  is  the  most  beautiful  sight  in  cystoscopy.  The  detection  and 
recognition  of  stones,  how^ever,  is  not  so  simple  as  might  be  supposed.  The 
position  of  stones  varies  quite  markedly  with  the  position  of  the  patient.    When 


FINDINGS   WITH   THE    CYSTOSCOPE  225 

the  patient  is  standinc,',  the  stone  tends  to  fall  down  into  the  depression  at  the 
neck  of  the  hladdcr.  Wlit-n  the  patient  is  lying  down,  the  stone  tends  to  fall 
l)ack  upon  the  posterior  wall  of  the  bladder.  When  recdining,  with  the  body 
elevated  at  a  moderate  angle  (1-45°  or  less),  the  stone  tends  to  rest  on  the 
trigone.  It  is  in  these  two  latter  positions  that  the  calculus  is  best  seen 
through  cystoscopy. 

The  appearance  of  stones  through  the  cystoscope  is  somewhat  deceptive,  as 
they  look  much  larger  than  they  really  are,  especially  if  the  cystoscope  is  brought 
close  to  them.  The  shape  of  the  stones  cannot  always  be  accurately  determined 
with  the  cystoscope  and  some  stones  which  seem  fairly  well  rounded,  appear  like 
lozenges  when  they  are  removed. 

One  of  the  difficulties  often  mentioned  in  the  diagnosis  of  stones,  is  the 
tendency  which  they  have  to  lodge  in  pockets.  This  is  not  so  common  as  was 
formerly  believed  before  the  cystoscope  was  in  use.  The  principal  pocket  for 
stones  is  in  a  posterior  prostatic  pouch  in  men,  and  in  a  cystocele  pouch  in 
women.  Cystoscopy  can  do  more  to  show  the  presence  of  pocketed  stones  than 
the  stone-searcher  or  any  other  method  save  exploratory  incision,  A  cystoscopic 
examination  should  be  made  in  every  case  in  which  stone  is  suspected,  and,  in 
fact,  in  every  case  of  chronic  cystitis  before  we  exclude  the  presence  of  stone. 
Vesical  calculi  are  sometimes  not  detected  by  cystoscopy,  and  I  have  seen  well- 
known  genito-urinary  surgeons  fail  to  see  them  when  situated  in  the  postpros- 
tatic  pouch. 

Tumors  of  the  Bladder. — These  can  be  properly  diagnosticated  only  with 
the  cystoscope.  They  vary  greatly  in  size  from  that  of  a  split  pea  to  that  of  an 
orange  and  are  either  infiltrating,  sessile  or  pedunculated,  the  sessile  form  being 
more  common.  If  malignant,  the  surface  may  appear  granular  and  red  or 
whitish  and  covered  with  pus  or  salts  like  ulcers  of  the  bladder.  Sessile  gTowths 
sometimes  appear  like  a  luminous  cone  in  the  crater  of  a  volcano,  while  at  other 
times  they  have  a  cauliflower  appearance  or  a  warty  surface.  Pedunculated 
tumors  are  usually  more  vascular,  and  the  growth  is  not  so  dense.  The  small, 
pCMJunculated  growths  have  numerous  tendrils  that  wave  about  as  they  are 
struck  by  columns  of  urine  shot  from  the  ureters. 

Tumors  of  the  bladder  frequently  bleed  so  that  it  is  impossible  to  use  the 
cystoscope  satisfactorily.  In  such  cases,  it  is  best  to  wash  out  first  with  hot 
boric  acid  and  then  to  use  a  solution  of  adrenalin.  This  often  stops  the  hemor- 
rhage, but  sometimes  defeats  the  purpose  of  the  examination,  as  the  adrenalin 
shrivels  up  the  tumors  to  such  a  degree  that,  wdien  small,  they  cannot  be  seen. 
In  one  ease  of  most  persistent  hemorrhage,  no  tumor  could  be  found  upon  cys- 
toscopic examination;  I  saw  simply  a  dark  area  on  the  anterior  wall  of 
the  bladder  which  could  be  barely  made  out  on  account  of  the  rapid  discolora- 
tion of  the  fluid.  The  tumor,  which  was  afterwards  discovered  at  the  opera- 
tion, was  no  larger  than  a   very  small  French  pea   and   was   directly   in   the 


226  CYSTOSCOPY 

line  of  the  incision  so  that  it  showed  only  when  the  retractors  were  taken 
away. 

The  posterior  wall  of  a  hypcrtrophied  prostate  at  times  simulates  a  tumor, 
in  that  it  resembles  a  new  growth  with  a  granular  surface  wdiich  projects  into 
the  bladder;  at  other  times  a  bladder  tumor  develops  on  the  base  of  the  en- 
larged prostate,  showing  itself  as  a  papilloma. 

Malignant  tumors,  especially  those  situated  about  the  trigone,  which  is  the 
favorite  location,  are  often  red  and  indurated,  their  color  sometimes  resembling 
the  coral  of  a  boiled  lobster.  These  tumors  usually  have  an  irregular  surface 
wdiicli  may  be  granular  or  lenticulo-papular. 

Eug?e  sometimes  resemble  papilloma,  especially  if  they  have  suffered 
from  traumatism.  When  we  first  began  to  use  the  direct  cystoscope  in 
the  clinic,  numerous  papilloma  w^ere  diagnosticated,  but  these  usually  disap- 
peared Avith  rest  and  bladder  washing.  Multiple  sessile  villous  tumors  of  the 
bladder  are  sometimes  seen,  but  slightly  elevated  and  covering  a  large  part  of 
the  bladder  area. 

In  prostatic  hypertrophy,  the  base  of  the  gland  often  projects  into  the  blad- 
der. A  dark  space  may  be  seen  behind  it,  which  is  a  favorite  seat  for  calculi. 
These  can  usually  be  seen  with  the  cystoscope  and  resemble  eggs  in  a  nest,  al- 
though they  are  occasionally  overlooked. 

Edema  Bullosum  Vesic.t:. — Of  the  forms  of  edema  which  affect  the 
human  bladder,  that  which  Kolischer  describes  as  "  edema  bullosum  "  is  per- 
haps the  most  characteristic,  and  certainly  the  most  interesting.  Circumscribed 
areas  of  the  vesical  mucous  membrane  appear  to  be  covered  by  vesicles  varying 
in  size  from  a  small  seed  to  a  pea,  often  closely  packed  together,  between  wdiich 
■white,  floating  particles  are  seen  adherent  at  one  end  to  the'  bladder  wall,  the 
probable  remains  of  ruptured  vesicles.  They  are  situated  near  some  inflam- 
matory tissue  pressing  against  the  bladder  wall,  as  carcinoma  of  uterus,  tumors 
of  the  prostate,  pelvic  tumors  and  in  connection  with  cystoscopic  burns,  pyosal- 
pinx,  parametritic  exudates  and  abscesses. 

Intravesical  Evidence  of  Perivesical  Processes  in  the  Eemale. — In 
women  with  bladder  symptoms,  a  condition  resembling  trabeculated  bladder  is 
often  seen.  Bierhoff  noticed  that  the  changes  were  confined  to  limited  por- 
tions of  the  bladder  wall  and  occurred  in  people  without  obstruction  or  difficulty 
in  urination,  but  wdio  were  suffering,  or  had  formerly  suffered,  from  parame- 
tritis or  similar  trouble.  He  examined  443  cases.  In  214,  there  was  a  history 
of  parametritis  or  perimetritis.  In  264,  there  were  symptoms  referring  to  the 
urinary  organs  present.     In  136,  pericystitic  strands  Avere  seen. 

In  cases  of  perivesical  inflammation,  the  cystoscopic  picture  varies  accord- 
ing to  wdiether  it  has  extended  to  and  involved  the  bladder  wall,  or  only  the 
adjacent  tissues.  If  the  process  is  recent,  the  exudate  encroaches  to  a  greater 
or  less  extent  ujDon  the  bladder,  the  distensibility  of  which  is,  to  a  corresponding 


CATHETERIZATION    OF    THE   URETERS  227 

degree,  impaired.  If  the  exudate  is  unilateral,  the  excursions  of  the  cystoscope 
are  limited  on  the  affected  side,  while  normally  free  on  the  unaffected  one. 
Similarly,  if  it  occupies  Douglas's  cul-de-sac,  the  uterus  tends  to  be  somewhat 
displaced  forward  and  tlui  excursions  are  limited  toward  the  posterior  wall  of 
the  bladder.  In  all  these  cases,  if  any  amount  of  exudation  is  marked,  the  blad- 
der wall  will  be  seen  to  bulge  inward  over  the  site  of  the  exudate.  When  an 
inflammatory  process  in  the  tissues  adjacent  to  the  bladder  extends  to  and  in- 
volves the  wall  of  this  viscus,  as  in  cases  of  salpingitis  and  perisalpingitis, 
"  edema  bullosmn  "  is  often  present. 

When  the  process  is  an  old  one  and  the  exudate  has  gone  on  to  organization, 
the  cystoscopic  picture  is  an  entirely  different  one.  In  the  same  way  that  dis- 
placements of  the  uterus  and  adnexa  may  be  caused  by  the  traction  of  the 
fibrous  strands,  resulting  from  the  contraction  and  organization  of  an  inflam- 
nuitory  exudate,  we  may  have  the  bladder  affected  by  these  strands  pulling  upon 
parts  of  its  wall.  The  most  characteristic  appearance,  however,  in  these  cases, 
is  the  presence,  over  parts  of  the  bladder  wall,  of  sharp,  scarlike  formations, 
which  rise,  to  a  greater  or  less  extent,  above  the  surrounding  wall,  have  a  yellow- 
ish-white color  and  tend  to  fimbriate  at  the  ends.  The  parts  usually  affected 
are  the  lower  lateral  and  the  upper  posterior,  and  the  postero-lateral  portions  of 
the  bladder. 

The  pericystitic  strands  are  limited  to  certain  circumscribed  portions  of  the 
bladder  wall,  and  are  less  marked  above  the  surface  than  regular  trabecula?.  They 
tend  to  have  fimbriated  extremities  and  are  of  sharp  contour.  These  conditions 
of  the  female  bladder,  described  by  Bierhoff,  were  frequently  noticed  by  me  in 
my  gynecological  ward  at  the  City  Hospital,  and  the  operations  confirmed  the 
cystoscopic  and  gynecological  examination  made.  His  admirable  description 
of  these  conditions  from  the  view  point  of  a  cystoscopist,  cleared  for  me  many 
an  uncertainty  which  I  did  not  understand  prior  to  reading  his  work. 

CATHETERIZATION   OF   THE   URETERS 

Catheterization  of  the  ureters  has  always  been  a  difficult  procedure  and  for- 
merly surgeons  went  abroad  to  learn  it,  when  they  could  as  well  have  mastered 
it  at  home  if  they  had  had  the  necessary  amount  of  patience.  Ordinarily  in 
the  past,  the  practitioner  bought  a  cystoscope  and  looked  for  a  case  to  work 
upon.  He  at  last  found  one  and,  not  being  familiar  with  the  details  of  the 
examination,  he  hurt  his  patient  and  did  not  accomplish  the  catheterization. 
After  a  few  more  trials,  he  usually  gave  it  up  and  put  his  cystoscope  awa^'  on 
the  shelf,  where  it  soon  became  an  unused  instrument. 

How  to  Acquire  the  Knowledge. — It  is  advisable  for  tlio  practitioner  to 
buy  a  phantom  (artificial)  bladder  (Fig.  213)  and  to  practice  upon  it  for  a 
while ;  or  to  use  for  this  purpose  half  of  a  rubber  ball  with  openings  correspond- 


228 


CYSTOSCOPY 


ing  to  the  urethra  and  the  ureters.     The  cystoscope  can  then  he  inserted  through 
tlie  urethral  opening  in  the  phantom  or  in  tlie  hall  and  he  can  practice  catheter- 

izing  the  other  two  openings. 

He  should  then  obtain  a  position  in 
some  clinic  with  the  necessary  clinical 
material,  and  every  day  he  should  keep 
certain  of  the  patients  after  the  others 
have  gone  and  practice  washing  out  tlieir 
bladders,  examining  them  and  searching 
for  the  ureters.  After  he  has  found 
them  in  the  way  I  have  spoken  of,  he  can 
catheterize  them,  although  it  might  re- 
quire three  months  to  find  them  easily 
in  normal  cases   (Fig.  214). 

In  everything  that  one  undertakes  in 
the  line  of  professional  work,  there  are 
difficulties  to  be  encountered.  It  is  diffi- 
cult to  palpate  the  pelvic  and  abdominal 
organs ;  to  detect  the  abnormal  sounds  in 
the  lungs  and  heart  with  the  stethoscope ; 
to  examine  intelligently  the  eye  with  the 
ophthalmoscope ;  to  make  a  diagnosis  of 
the  condition  of  the  larynx;  to  see  the 


Fig.  213. — Phantom  Blad- 
der FOR  Practicing 
1  Cystoscopy  and  Ure- 
teral Catheteriza- 
tion. 


Fig.  214. — Catheterization  of  the  Ureters.     The  relative  position  of  the  cystoscope  to  the  uret«r 
and  the  operator  just  about  to  push  the  catheter  in  by  the  direct  method. 


CATIIETERTZATTON    OF    THE    URETERS 


229 


posterior  uares,  or  to  catlictcrizo  tlio  Eiistacliian  tiihcs.  It  is  also  ditticull  to 
cystoscope  a  patient  and  catlieterize  the  ureters,  and  one  must  not  be  discour- 
aged because  he  fails  and  hears  those  who  have  acquired  the  art  speak  of  it  as 
easy.  It  must  be  remembered  that  no  one  is  born  a  cystoscopist  and  that  every- 
onc!  who  learns  cystoscopy  causes  more  or  less  harm  to  patients'  bladders  before 
he  becomes  pr.oficient. 

I  have  seen  the  most  expert  surgeons  fail  to  catheterize  the  ureters  after 
trying  for  an  hour  and  a  half.  I  have  seen  them  at  times  fail  in  two  cases  out 
of  three  even  after  they  have  had  long  experience. 

In  order  to  acquire  the  cystoscopic  eye  and  the  cystoscopic  fingers,  one  must 
look  many  times  into  the  bladder  and  into  many  bladders.  He  must  cultivate 
jjersistence,  patience  and  precision.     It  is  easy  for  a  man  in  a  large  city  to  learn. 


Fig.  215. — The  Same  Position  as  in  Fig.  214,  to  Show  the  Position  of  the  Hands  in 

Catheterization. 


if  he  is  willing  to  take  the  time,  for,  after  trying  a  number  of  times  without 
success,  he  can  go  to  one  of  his  friends  interested  in  that  branch  who  will  show 
him  the  way;  but  in  smaller  communities  it  is  more  difficult,  and  one  is  more 
easily  discouraged  if  he  is  not  persistent.  A  well-known  surgeon  in  a  city  of 
l.''>0,00()  inhabitants  in  which  there  was  no  one  who  could  do  cystoscopy  or  cathe- 
terize the  ureters,  cut  both  ureters  in  doing  a  hysterectomy.  He  concluded  that 
if  the  patient  had  had  catheters  in  the  ureters,  the  accident  would  not  have 
lia])p('ucd  and  lie  accordingly  l)()ught  an  air-cathetcrizing  cystoscopc.  He  exam- 
ined bladders  religiously  for  one  year  before  he  could  see  the  ureters.  He  was 
then  able  to  find  them  and  he  catheterized  fifty  successive  cases  before  doing 
hysterectomy.  He  accomplished  his  purpose  and  for  a  long  time  was  the  only- 
thorough  cystoscopist  in  his  city. 


230 


CYSTOSCOPY 


The  Instruments. — At  present  all  the  models  of  cathGtorizinf>:  cystoscopes 
made  in  this  country  have  the  double  canal  and  can  be  nscd  for  observation  as 
Avell ;  therefore,  in  considering-  the  subject  of  catheterizing  the  ureters,  only  the 
double-cathetcrizing  instruments  will  be  mentioned.  The  ureteral  catheters 
should  be  Nos.  C  to  8  French  scale,  the  latter  being  the  better  size  to  prevent  the 
leakage  of  urine  along  the  sides.  A  catheter  with  a  tip  No.  6  French  gradually 
increasing  in  size  toward  the  proximal  end  is  most  desirable. 

The  Direct  Instrument. — The  nreters  having  been  seen  as  outlined 
under  cystoscopy,  a  catheter  is  first  passed  up  the  ureteral  opening  on  one 
side  and  then  the  instrument  is  moved  along  the  interureteral  band  to  the 

other  ureter,  and  the  remain- 
ing catheter  is  pushed  up  in 
the  same  way  (Figs.  215, 
216). 

The  same  method  applies 
to  the  air  cystoscope,  which  is 
also  direct.  When  the  ure- 
teral orifice  cannot  be  seen, 
more  water  should  be  added 
by  the  piston  syringe,  in  the 
case  of  water  cystoscopy ;  or 
more  air  by  means  of  a 
pump,  if  the  air  cystoscope  is 
used. 

The  Indirect  Instru- 
ment.— The  Bierhoff  instru- 
ment is  the  one  used  in  this 
description,  and  presents 
more  difiiculties  in  ureteral 
catheterization  than  does  the 
direct  instrument,  as  it  is 
necessary  to  move  the  cathe- 
ter toward  the  ureter  in  an 
angle  instead  of  in  a  straight 
line.  In  other  words,  one 
must  dip  the  end  of  the  cathe- 
ter into  the  opening  instead 
of  pushing  it  straight  in.  It 
must  be  remembered  that,  as  the  image  is  inverted,  the  movement  is  liable  at 
first  to  appear  ataxic,  and  the  examiner  must  consequently  learn  to  turn  the 
wheel  on  the  side  of  the  shaft  in  what  seems  to  be  the  wrong  way,  in  order  to 
make  the  point  of  the  catheter  move  in  the  right  direction.     The  ureters  are 


Fig.  216. — Catheterization  of  the  Ureters.  The  right 
ureter  has  been  eatheterized  by  the  direct  method  and  the 
beak  of  the  instrument  moved  across  the  interureteral  band 
with  the  catheter  in  the  left  ureter. 


CATHETERIZATION    OF    THE   URETERS 


231 


at  tlio  extremities  of  the  hypothemise  of  a  triangle  represented  by  the  inter- 
urctcral  band,  the  apex  of  which  is  the  internal  urinary  meatus.  In  looking 
for  the  ureters,  the  floor  of  the  bladder  must  be  compared  to  the  dial  of  a  watch, 
the  central  point  of  which  should  be  that  from  which  the  catheter  protrudes  from 
the  instrument,  in  which  case  the 
opening  of  the  right  ureter  should 
correspond  to  twenty-five  minutes 
before  the  hour  and  the  left  ureter 
twenty-five  minutes  after. 

When  the  catheter  is  in  place 
and  the  examiner,  looking  at  the 
ureteral  mouth,  endeavors  to  in- 
sert the  tip  of  the  catheter,  he 
finds  that  it  tends  to  catch  on  the 
side  of  the  trigone,  or  reach  over 
it.  The  wheel  on  the  side  of  the 
shaft  of  the  instrument  is  then 
turned,  which  projects  a  knee  or 


finger  on  the  concave  surface  of 
the  instrument  near  its  base  in 
such  a  way  that  it  moves  the  end 
of  the  catheter  in  front  of  the 
ureter  mouth.  When  the  catheter 
tip  has  reached  this  position,  the 
fingers  are  removed  from  the 
wheel  and  grasp  the  catheter  and 
gently  push  it  into  the  ureter. 
The  finger  is  then  turned  down 
again  and  the  other  ureter  is  lo- 
cated. During  this  latter  pro- 
cedure, the  first  catheter  moves 
entirely  out  of  the  field  of  vision, 
and  may  be  entirely  disregarded 
by  the  operator.  The  second  ureter 
is  now  catheterized  (Fig.  217), 
the  knee  again  tTirned  down  and 
the  instrument  turned  so  that  the  operator  may  assure  himself,  before  with- 
drawing it,  that  both  catheters  are  in  situ  (Figs.  218  and  219).  The  cystoscope 
is  then  turned  within  the  catheterizing  portion,  so  that  the  beak  points  toward 
the  median  line  of  the  abdominal  wall,  the  catheterizing  portion  meanwliile 
being  held,  and  continuing  to  jioint  downward.  The  instrument  is  then  slowly 
withdravv-n,  its  removal  being  compensated  for  by  a  gradual  insertion  of  more 


Fig.  217. — Catheterization  of  the  Ureters.  The 
catheter  in  the  left  ureter,  and  on  the  other  side,  in 
dotted  lines,  the  movement  of  the  catheter  before 
entering  the  right  ureter  in  catheterization  by  the 
indirect  method. 


232  CYSTOSCOPY 

of  the  catheters  into  the  cannnljr.  When  the  knees  of  the  instrument,  Avith  the 
catheters,  appear  at  the  meatus,  the  catheters  are  fixed  at  the  urethral  orifice 
M-ith  one  liand,  and  the  cystoscope  steadily  withdrawn  with  the  other.  In 
performing  cystoscopy,  the  catheters  should  be  of  different  colors,  so  that  they 


Figs.  218-219. — Catheterization  of  the  Ureters.  The  Catheters  in  situ.  In  the  first  figure 
the  ureteral  catheter  points  to  "  twenty-fi.ve  minutes  before  the  hour,"  and  in  the  second  to 
"  twenty-five  minutes  after." 

can  be  easily  distinguished  from  one  another,  as  a  black  and  a  brown,  or  a  black 
and  a  striped  catheter.  The  collecting  bottles  should  also  be  marked  right  and 
left.  It  is  thus  an  easy  matter  to  distinguish  and  collect  the  separated  urines. 
With  the  present  system  of  lenses  in  the  Wappler  cystoscopes  the  image  is  not 
inverted  and  the  catheters  can  easily  be  introduced  without  resorting  to  the 
maneuvers  just  described. 

Should  the  urine  become  turbid  during  the  course  of  the  examination,  the 
catheters  should  be  withdrawn  and  rubber  tubes  attached  to  the  irrigating  noz- 
zles connected  with  the  cannula^,  after  which  the  solution  should  be  forced 
through  one  of  the  tubes  from  a  fountain  or  piston  syringe.  The  streams 
then,  flowing  through  separate  tubes,  are  kept  distinct,  and  the  one  tube  may 
be  used  for  the  inflow,  the  other  for  the  outflow.  In  refilling,  after  irrigation, 
one  stopcock  is  closed,  and  the  bladder  filled  through  the  other  tube. 

The  Rhythm  of  Ureteral  Secretion — How  to  Remedy  It  When  Interfered 
with. — After  the  catheters  are  inserted,  the  plugs,  if  used,  are  removed  from 
the  ends  and  the  urine  is  collected  in  different  test-tubes  or  bottles.  Xormally 
the  urine  will  be  seen  to  come  in  dribbles,  interrupted  periodically,  each  dribble 
consisting  of  about  ten  or  twelve  drops.  If  the  urine  does  not  flow  from  one 
side,  it  is  probable  that  the  catheter  is  blocked  with  pus  or  mucus,  and  should 
be  aspirated.  If  this  is  not  successful  in  reestablishing  the  flow,  a  small  but 
measured  amount  of  boric-acid  solution  should  be  injected  to  clear  the  cathe- 


CATIIETEKIZATION    OF    THE   URETERS  233 

tcr,  l)y  iiicaiis  of  u  liaiul  syringe  iiiscrlocl  info  tlic  end  of  tlic  catheter.  It 
nmst  be  noted  whether  this  all  comes  away  or  not  and  its  appearance  after  it 
comes  away  as  compared  with  the  solntion  before  injection,  A  clear  fluid  in- 
jected and  a  turbid  one  coming  away  wonld  indicate  pus ;  a  bloody  one  coming 
away,  hemorrhage ;  a  less  amount  of  turbid  fluid  coming  away  would  show  that 
some  debris  has  plugged  the  catheter.  If  the  fluid  comes  away  clear,  it  shows 
that  the  pelvis  is  normal.  If  no  fluid  enters,  it  shows  that  the  catheter  was 
l)lugged  before  using  it  and  it  should  be  withdrawn  and  cleaned,  or  else  an- 
other one  used.  This  shows  the  importance  of  testing  the  catheters  always 
before  using  them  and  w^ashing  them  out  immediately  afterwards.  If  but  one 
iireler  can  be  catheterized,  a  soft-rubber  catheter  should  be  left  in  the  emptied 
bladder  to  collect  the  urine  from  the  other  kidney. 

The  catheterization  of  both  ureters  at  the  same  time  is  very  important,  as  it 
shows  us  the  comparative  secreting  activity  of  the  kidneys.  We  know  that  the  kid- 
neys secrete  normally  about  forty-eight  ounces  of  urine  in  twenty-four  hours ;  or 
that  each  organ  will  average  an  ounce  an  hour.  This  gives  a  certain  standard  for 
us  to  compare  the  urines  with,  although  we  know  that  there  are  certain  conditions 
depending  upon  ureteral  catheterizations  wdiich  influence  in  a  way  the  secre- 
tion of  urine.  Changes  in  the  rapidity  of  secretion  of  the  two  specimens,  of 
the  color  and  the  clearness  are  also  noted,  as  well  as  the  appearance  of  the 
coloring  matter  in  case  it  is  given  for  testing  the  function  of  the  respective 
kidneys. 

If,  on  inserting  a  ureteral  catheter  into  the  pelvis  of  the  kidney,  a  few 
drachms  of  urine  of  normal  appearance  pours  down  from  that  side,  it  is 
a  case  of  renal  retention ;  whereas,  if  it  be  of  a  whitish,  turbid  flow,  pyonephrosis 
is  probably  present  in  that  kidney. 

The  primary  purpose  of  ureteral  catheterization  is  the  determination  of  the 
presence  of  both  kidneys,  their  function  and  a  comparative  examination  of 
the  urine  from  each.  After  the  urines  from  each  side  have  been  collected,  they 
should  be  examined  separately,  and  the  examination  recorded  on  blanks  marked 
ri(j]i(  and  left  l-idney. 

Diagnostic  Value  of  Ureteral  Catheterization  in  Ureteral  Diseases. — Ure- 
teral catheterization,  furthermore,  is  useful  to  recognize  the  presence  of  and  to 
locate  obstruction  in  the  ureter  due  to  strictures,  bends  or  kinks  (movable  kid- 
ney), valvular  formation,  stones  and  the  pressure  of  bands  of  adhesions  or 
adjacent  tumors.  Furthermore,  this  procedure  may  be  employed  for  the 
diagnosis  of  inflammation,  distention  or  suppuration  in  the  pelvis  of  the 
kidney. 

Ureteral  Catheterization  as  a  Therapeutic  Procedure. — As  a  therapeutic 
pi'oeedure,  catheterization  may  be  resorted  to  lor  the  purpc^se  of  increasing  kid- 
ney drainage  by  dilating  the  narrowest  parts  of  the  ureter;  for  the  ]iurpose  of 
irrigating  and  treating  the  ureters  and  the  pelvis  when  they  are  inflamed.     A 


234  CYSTOSCOPY 

catheter  in  tlie  ureter  can  also  be  employed  as  a  guide  in  some  abdominal  and 
pelvic  operations,  and  as  a  means  of  permanent  drainage.  By  introducing  a 
catheter,  provided  with  a  silver  or  lead  mandrel,  and  then  exposing  the  abdomen 
to  X-rays,  the  course  of  the  ureter  can  be  accurately  mapped  out  and  strictures, 
calculi  or  displacements  of  the  renal  pelvis  can  he  detected. 

The  Importance  of  Ureteral  Catheterization  in  Pelvic  Operations. — Ure- 
teral catheterization  is  also  an  important  step,  prior  to  hysterectomy,  in  cases  of 
malignant  growths  of  the  uterus,  as  the  independent  tumors  in  the  abdomen,  not 
connected  with  the  kidneys  or  ureters,  can  thus  be  made  out. 

Dangers  and  Complicatons  of  Ureteral  Catheterizations. — These  are  gen- 
erally slight,  provided  two  conditions  are  fulfilled.  The  first  is  not  to  work  too 
long  on  any  one  occasion,  but,  if  unsuccessful  after  working  a  short  time,  to 
have  the  patient  call  again  and  to  repeat  the  calls  imtil  the  catheterization  is 
successful.  The  second  important  point  is  to  be  careful  not  to  use  undue  vio- 
lence in  the  introduction  of  the  instrument.  It  is  needless  to  mention  the  im- 
portance of  as  perfect  asepsis  and  antisepsis  as  possible,  both  in  the  preparation 
of  the  bladder  for  the  eucain  or  cocain,  and  in  every  manipulation  connected 
with  the  procedure. 

It  is  remarkable  how  rarely  infections  of  the  pelvis  and  ureters  occur  if 
proper  precautions  are  taken  in  catheterizing  the  ureters.  At  the  Post-Gradu- 
ate  Clinic,  where  several  hundred  cystoscopies  and  ureteral  catheterizations 
have  been  performed  in  the  past  few  years,  no  distinct  cases  of  renal  or  pelvic 
infection  following  ureteral  catheterization  have  been  noticed,  although  numer- 
ous attacks  of  urinary  fever  have  followed  in  patients  whose  urethra,  bladder 
or  kidneys  were  already  infected.  The  prophylactic  injection  of  solutions  of 
silver  nitrate,  1 :  2,000,  with  a  syringe  through  the  ureteral  catheter  and  into 
the  pelvis  of  the  kidney,  and  the  washing  of  the  bladder  with  the  same  solution 
after  every  ureteral  catheterization,  has  been  carried  out  in  these  cases  as  a  mat- 
ter of  routine.  This  has  proved  to  be  a  useful  precaution  against  the  exten- 
sion of  existing  infections  and  the  prevention  of  a  new  infection. 

It  must  be  remembered  that  a  certain  amount  of  blood  and  a  certain  number 
of  ureteral  epithelia  are  often  found  in  the  catheterized  specimens  of  urine,  sim- 
ply as  a  result  of  the  mechanical  effect  of  the  catheters  upon  the  mucous  mem- 
branes. This  should  be  borne  in  mind  in  judging  the  results  of  the  urinary 
examinations  of  the  separate  urines. 

Ureteral  catheterization  has  now  become  so  universally  recognized  as  a 
method  of  diagnosis  and  treatment,  that  it  is  no  longer  necessary  to  plead  in 
its  favor  or  to  refute  the  attacks  which  have  been  made  upon  it  by  surgeons 
who  were  so  conservative  that  they  did  not  care  to  employ  this  procedure.  The 
technique  is  difficult  to  acquire,  but  with  practice,  patience  and  perseverance, 
there  is  no  reason  why  anyone  possessed  of  moderate  dexterity,  cannot  become 
expert. 


CYSTOSCOPY   IN    AUTIIOli'S    CLINIC  235 

EVOLUTION   OF   CYSTOSCOPY  IN   THE   AUTHOR'S   CLINIC 

For  a  loii^-  time,  altliouiili  tlicro  Averc  assistants  in  the  clinic  who  Lad 
studied  cystoscopy  and  ureteral  catheterization  abroad,  the  cystoscopy  was 
])erformed  by  me  alone  and  none  of  thoni  coidd  catheterize  the  ureters. 
To  remedy  this  state  of  affairs,  I  accordingly  established  a  cystoscopic  room, 
which  was  probably  the  first  one  in  this  country,  connected  with  a  clinic 
for  routine  cystoscopy.  ISTow  every  assistant  coming  to  the  clinic  has  to 
go  through  a  certain  course  of  service — three  months  in  each  department 
of  the  clinic — so  that  it  requires  from  one  to  two  years  for  him  to  reach  the 
cystoscopic  room.  Here  he  is  on  duty  for  three  months,  washing  out  bladders 
and  preparing  patients  for  cystoscopy,  and  then  for  three  months  more  in  per- 
forming cystoscopy  and  in  catheterizing  the  ureters,  at  the  end  of  which  time 
he  has  become  very  proficient. 

The  result  has  been  that  we  have  developed  a  cystoscopic  school  and  some 
of  the  most  expert  cystoscopists  in  this  country  have  served  terms  in  our  clinic. 

It  requires  about  six  weeks  for  each  man  to  become  acquainted  with  the 
bladder,  and  six  weeks  more  for  him  to  be  able  to  catheterize  the  ureters.  For- 
merly, physicians  returning  from  Europe  were  constantly  telling  us  about  the 
dexterity  with  which  certain  surgeons  abroad,  who  taught  them,  could  cathe- 
terize the  ureters.  When  they  attempted  to  show  their  technique,  however,  they 
usually  failed.  At  present,  they  find  that  our  methods  of  catheterization  are 
the  simplest  and  that  our  cystoscopists  have  more  speed  than  those  in  Europe. 
On  one  occasion  when  the  question  of  quickness  was  being  discussed  by  a  body 
of  men  visiting  the  clinic,  I  requested  the  cystoscopist  in  charge  of  the  room 
to  illustrate  the  speed  of  our  American  method.  He  filled  the  patient's  bladder 
with  solution,  inserted  the  cystoscope  and  catheterized  both  ureters  in  twenty- 
nine  seconds. 

I  do  not  approve  of  these  trials  of  speed  and  it  was  the  only  time  in  our 
work  of  ureteral  catheterization  in  the  clinic  that  it  has  been  indulged  in,  as  I 
feel  that,  while  showing  the  dexterity  of  the  operator,  it  detracts  from  the  care- 
ful and  conservative  methods  which  it  is  our  endeavor  always  to  carry  out  in 
bladder  Avork. 

After  the  cystoscopic  examination,  cither  for  observation  or  ureteral  cathe- 
terization, is  finished,  the  patient  is  again  placed  in  the  horizontal  position,  a 
catheter  is  introduced  and  the  bladder,  is  emptied,  after  which  it  is  washed  out 
with  a  1 :  4,000  solution  of  nitrate  of  silver,  as  is  also  the  urethra. 

Fifteen  grains  of  urotro])in  in  a  glass  of  Avatcr  is  given  by  mouth,  and  a 
suppository  is  inserted  containing  ten  grains  of  quinin  and  one  quarter  of 
a  grain  of  morphin  to  prevent  an  attack  of  urethral  fever. 

Fig.  220  is  a  chart  showing  bladder  laid  open,  used  by  me  in  depicting  blad- 
der lesions  seen  by  cystoscopy. 


236  CYSTOSCOPY 

Reaction  after  cystoscopy  is  due  to  the  ])iitient's  spasmodic  resistance  to  the 
passai»'e  of  the  instrument  through  the  urethra,  which  causes  a  traumatism  and 
consequently  a  urethral  fever  in  case  the  urine  or  the  canal  is  infe('t(!d.  This 
is  intensified  in  a  damaged  condition  of  the  kidneys.     A  slight  reaction  may 


Fig.  220. — Diagrams  of  Bladder  used  for  Keeping  Records.     Shows,  on  the  left,  the  base, 
posterior  and  part  of  lateral  walls,  and  on  the  right,  the  anterior  and  lateral  walls. 

occur  even  though  asepsis  and  antisepsis  is  perfect,  and  the  bladder  and  nrethra 
are  washed  out  after  it  by  silver  solution,  and  morj^hin  and  quinin  solution  is 
given. 

QUESTIONS   REGARDING   CYSTOSCOPY 

In  concluding  this  chapter,  I  will  consider  the  questions  that  have  been  so 
frequently  asked  me  regarding  cystoscopy : 

(1)  Which  is  the  better  instrument,  the  direct  or  the  indirect? 

(2)  Which  is  the  better  instrument,  the  air  or  water  cystoscope  ? 

(3)  Which  is  the  easier  to  catheterize,  a  man  or  a  woman  ^ 

(1)  As  to  the  question,  which  is  the  better  instrument,  the  direct  or  in- 
direct, I  will  say  that  the  indirect  is  the  better.  This  is  especially  true  in 
the  hands  of  the  cystoscopist  who  is  an  exjiert  in  the  use  of  both  instruuients^ 
as  with  an  indirect  you  can  examine  the  interior  of  the  bladder  better,  which  is 
the  object  of  cystoscopy.  You  can  also  see  and  pass  the  catheter  into  any  ureter 
that  can  be  catheterized  by  the  direct  instrument,  besides  introducing  it  into 
many  ureters  that  cannot  be  catheterized  by  the  direct  cystoscope  on  account 
of  an  enlarged  prostate,  a  displaced  or  deformed  bladder,  or  a  cystocele. 


QUESTIONS   REGARDING    CYSTOSCOPY  237 

With  the  direct  instrnnieiit,  it  is  iinicli  easier  to  catheterize  the  ureters  of 
ninety-five  j)er  cent  of  the  patients,  if  this  percentage  can  be  catheterized ;  I 
feel  quite  certain  that  they  cannot  be,  the  first  time,  in  patliological  cases.  Once 
the  ureters  are  seen,  the  catheters  can  easily  be  introduced,  as  they  are  simply 
pushed  straight  into  the  openings.  The  direct  cystoscope,  however,  does  not 
give  the  examiner  as  good  a  view  of  the  entire  bladder  and,  therefore,  is  not 
such  a  good  instrument  for  observation.  This  led  me  to  bring  out  the  cystoscope 
that  I  have  described,  as  it  stands  for  the  teaching  in  the  clinic — ^namely,  ex- 
amine the  bladder  with  the  indirect  telescope ;  withdraw  it,  introduce  the  direct- 
catheterizing  apparatus  and  catheterize  the  ureters. 

( 2 )  Which  is  the  better  instrument,  the  air  or  the  water  cystoscope  ?  The 
Avater  cystoscope  is  certainly  better,  as  the  indirect  instrument,  which  is  the 
best  general  cystoscope,  can  only  be  used  successfully  in  a  water  medium. 

There  is,  consequently,  remaining  for  discussion,  only  that  part  of  the  ques- 
tion as  to  the  relative  merits  of  direct-air  and  w^ater  cystoscopes,  and  here  again  I 
believe  that,  in  the  great  majority  of  cases,  the  direct-water  cystoscope  is  prefer- 
able. A  bladder  dilated  with  water  is  more  tolerant  than  when  dilated  with 
air,  and  it  is  less  liable  to  traumatism,  as  the  maneuvers  are  made  in  a  field 
full  of  an  antiseptic  solution. 

Formerly  the  air  cystoscope  could  not  be  used,  as  the  cystoscopic  lamps 
were  too  hot  and  ^vould  burn  the  bladder,  and  cystoscopy  had  to  be  performed 
in  a  water  medium.  The  advent  of  the  Mignon  cold  lamp,  brought  out  by  Pres- 
ton of  the  Electro-Surgical  Company  of  Rochester,  and  introduced  into  the 
instruments  devised  by  Dr.  Koch  and  Dr.  Lewis,  made  air  cystoscopy  practical, 
on  account  of  the  bladder  being  able  to  tolerate  the  cold  lamp. 

There  are  advantages  that  an  air  cystoscope  has  in  certain  cases,  as,  for  in- 
stance, when  a  large  amount  of  pus  is  coming  down  the  ureter  from  a  kidney 
and  clouding  the  fluid  in  the  bladder  or  when  blood  coming  from  the  kidney 
renders  the  fluid  medium  difficult  to  see  through,  in  either  of  which  cases  the 
diseased  kidney  would  be  determined  and  the  ureters  easily  catheterized  by  the 
air  instrument.  It  is  also  valuable  in  certain  cases  of  cystitis  with  bladder  sac- 
culation. In  the  treatment  of  certain  conditions,  it  should  be  more  suitable 
than  the  water  instrument,  as  in  curetting  or  cauterizing  ulcers  of  the  bladder. 

It  is,  however,  a  more  difficult  instrument  to  use  than  the  water  cystoscope, 
as  the  jiatient  complains  of  pain,  and  is  kept  in  position  with  difficulty ;  while 
the  leaking  of  air,  and  the  bubbling  up  of  air  and  urine  disturbs  the  composure 
of  the  examiner.  These  causes  have  been  sufficient  to  make  the  majority  of 
the  practitioners  who  have  purchased  the  instrument  put  it  away,  and  its  use 
is  limited  to  the  specialist  with  an  abundance  of  material.  There  is,  however, 
a  great  field  for  the  air  cystoscope  if  alterations  can  be  made  by  which  the  patho- 
logical field  in  the  bladder  can  be  kept  sufficiently  smoothed  out  by  air  dilatation 
to  allow  operative  work  to  be  done  through  the   instrument.      A  cystoscopist 


238  CYSTOSCOPY 

should,  therefore,  be  able  to  use  the  direct  and  indirect  water,  air  and  catheter- 
izing  cystoscoije  equally  well,  in  order  to  be  proficient  in  his  specialty. 

(3)  Which  are  the  easier  to  catheterize,  men  or  women?  This  may  be  an- 
swered by  stating  that  it  is  easier  to  introduce  the  instrument  into  the  fenuile 
bladder  than  into  the  male,  but  once  introduced  it  is  more  difficult  to  make  the 
examination  in  the  female.  This  is  because,  in  the  female  bladder,  the  land- 
marks are  not  so  clearly  defined,  and  also  because,  in  women,  the  pelvic  con- 
tents are  not  always  normal,  especially  the  internal  genitals.  Uterine  displace- 
ments change  the  shape  of  the  bladder  and  its  relations,  as  do  fibroid  tumors, 
the  adhesions  of  exudates  about  the  tubes,  the  presence  of  ovarian  tumors  and 
the  prolapse  of  the  posterior  wall  in  cystocele. 


CHAPTEK    XI 

SPECIAL  URINARY  SYMPTOMS 

I.   DISTURBANCES    OF   MICTURITION 

Frequency  of  Ueinatiok 

(Pollakiuria) 

rREQUENCY  of  iirination  is  perhaps  the  most  common  form  of  urinary  dis- 
turbance. The  normal  frequency  of  urination  varies  somewhat  in  different 
individuals  and  at  different  times.  A  healthy  person,  with  a  normal  urinary 
tract  not  pressed  upon  or  interfered  with  by  anything  outside  of  its  walls,  passes 
urine  five  times  a  day  without  any  difficulty  or  pain,  and  with  a  stream  of  good 
size  which  can  be  started  or  stopped  at  will.  At  the  end  of  the  act,  the  bladder 
is  empty  and  no  sense  of  discomfort  will  be  felt  in  any  part  of  the  tract.  Urina- 
tion usually  takes  place  on  arising ;  at  the  time  of  the  stool ;  before  the  midday 
meal ;  before  the  evening  meal  and  on  retiring. 

The  temperature  plays  an  important  role  in  the  frequency  of  urination. 
During  the  hot  weather  when  the  skin  is  active,  much  fluid  is  taken  from  the 
body  in  the  perspiration  and  the  amount  of  urine  and  the  frequency  tend  to 
diminish,  excepting  when  the  individual  is  in  bathing,  when  the  desire  is  much 
increased.  In  the  autumn,  the  skin  becomes  less  active,  additional  work  is 
thrown  upon  the  kidneys  and  the  frequency  is  increased.  Wetting  the  feet  in 
the  fall  of  the  year  or  chilling  of  the  legs  increases  the  amount  of  fluid  voided 
by  producing  a  congestion  of  the  internal  urogenital  tract  and,  therefore,  an 
irritability  of  the  urinary  organs  bringing  on  the  desire.  Autumn  frequency 
is  often  caused  by  sitting  or  standing  quietly  watching  some  game  or  other 
object  of  interest,  when  the  circulation  is  active  and  the  extremities,  on  account 
of  not  being  well  covered,  are  chilled.  This  tendency  disappears  during  the 
winter  when  the  extremities  are  better  protected  by  heavier  clothing  and  over- 
coats. The  frequency,  perhaps,  returns  in  the  spring  from  a  different  cause — 
the  sudden  begimiing  of  active  perspiration  which  takes  a  certain  amount  of 
fluid  from  the  urine  and  renders  it  more  concentrated  and  irritating. 

The  amount  of  exercise  has  the  same  effect  as  heat,  in  that  it  increases  the 
activity  of  the  circulation  and  consequently  perspiration,  when  the  quantity  of 
urine  is  temporarily  diminished. 

239 


240  SPECIAL    T'RTXARY    .SY]\IPTOMS 

^Mental  emotions  i»ive  rise  to  many  varieties  of  frequenev^  -wliifli  may  nliow 
themselves  in  an  unexpected  desire  to  nrinate,  as  in  the  case  of  sudden  fright. 
At  other  times  frequency  is  increased  wlien  waiting  to  take  part  in  some  event, 
competition  or  game,  in  which  the  participant  is  especially  interested;  in  which 
case,  before  l)eginning,  it  may  he  necessary  to  urinate  three  times  in  an  hour, 
whereas  perhaps  a  few  minutes  after  the  affair  is  over,  tlie  desire  is  gone  and 
will  not  occur  again  for  several  hours. 

Mental  association  or  continuous  thought  centered  upon  tlio  urinary  organs 
may  have  the  same  effect,  as  students  working  on  the  sulijoct  eitlier  in  a  literary 
or  clinical  way,  hut  especially  the  former. 

Pathological  frequency  of  urination  or  bladder  irritability  is  a  condition 
in  which  the  urine  is  not  only  voided  more  frequently  than  normal,  l)ut  in  which 
the  desire  to  urinate  is  present  again  soon  or  immediately  after  voiding  it.  The 
frequency  of  micturition  observed  in  disease  is  variable,  ranging  from  six  urina- 
tions in  the  daytime  and  one  at  night,  to  an  almost  continuous  desire,  or  a  mic- 
turition every  few  minutes. 

Etiology. — Frequency  of  urination  is  due  to  troubles  independent  of  the 
urinary  tract ;  to  diseases  of  the  urinary  tract ;  to  affections  outside  of  the 
urinary  tract  that  interfere  with  its  (the  urinary  tract's)  function. 

(1)  Diseases  iNDEPEiiTDENT  of  the  Urinaky  Tract. — The  diseases  inde- 
pendent of  the  urinary  tract  causing  frequency  of  urination  are  those  of  me- 
tabolism, as  diabetes  mellitus  and  insipidus,  giving  rise  to  overproduction  of 
urine ;  nervous  disorders,  as  hysteria,  neurasthenia  and  hypochondriasis  pro- 
ducing an  increased  amount  of  urine ;  or  the  character  of  the  urine  itself,  as  a 
highly  acid  urine  or  one  containing  an  increased  amount  of  uric  acid,  oxalate 
of  lime  or  indican,  the  results  of  faulty  metabolism  through  irritation  of  the 
kidney  and  the  consequent  polyuria. 

Frequency  may  also  follow  certain  articles  of  diet,  as  pepper  and  other  con- 
diments; an  abundance  of  spring  water;  mineral  diuretics,  alcoholic  drinks, 
especially  gin  and  beer;  certain  foods  giving  rise  to  intestinal  fermentations,  as 
sweets,  fried  food,  onions,  radishes,  cabbage,  tomatoes;  also  a  diet  too  rich  in 
meat  which  may  give  rise  to  intestinal  jDutrefaction.  These  articles  of  food, 
if  not  properly  digested,  give  rise  to  the  products  of  faulty  metabolism  already 
mentioned:  indican,  uric  acid,  diabetes,  oxaluria,  etc. 

(2)  Diseases  of  the  Uria^aky  Tract  Giviis-^g  Eise  to  Frequency  of 
Urination. — The  diseases  of  the  urinary  tract  causing  this  trouble  are  situated 
above  and  below  the  middle  zone  of  the  bladder,  principally  in  the  latter.  Above 
this  zone,  we  have  the  kidney,  which  causes  pollakiuria,  owing  to  a  polyuria. 
The  polyuria  is  generally  due  to  an  interstitial  nephritis,  to  a  tubercular  nephri- 
tis in  its  early  stages  and  sometimes  to  the  irritation  of  a  renal  calculus.  An 
intermittent  pollakiuria  is  sometimes  jDresent  in  the  ease  of  a  movable  kidney 
that  has  become  displaced,  wdiere  there  is  an  intermittent  hydronephrosis,  which 


DISTUKBANCES    OF   MICTURITIOX  241 

on  its  return  to  position  pours  ont  a  sufficient  amount  of  nrine  to  give  rise  to 
frequency  for  a  brief  period. 

The  bladder  is,  however,  usually  responsible  for  frequency  of  urination,  due 
to  a  congestion  or  inflanniiation  of  its  wall  as  a  result  of  the  irritation  from  a 
foreign  body,  as  a  calculus  in  its  cavity,  from  tubercular  deposits  or  ulcers  in  its 
wall,  from  tumor,  or  indirectly  from  the  back  pressure  owing  to  some  obstruc- 
tion in  the  tract  below,  as  the  prostate  or  the  urethra;  or  from  an  extension  oi' 
an  inflammation  from  the  urethra. 

Most  of  the  troubles  in  the  bladder  giving  rise  to  frequency,  are  those  situ- 
ated in  the  part  below  what  would  correspond  to  the  middle  zone  of  an  organ 
in  health  Avhcn  full  of  fluid.  This  would  include  the  base  or  fundus  from  the 
intei-nal  meatus  to  a  line  above  the  interureteral  band,  thus  including  the 
trigone. 

A  caJcuhis  in  this  position  when  the  patient  is  standing,  sitting  or  moving 
ab(iut,  would  give  rise  to  irritation  and  consequent  congestion  of  the  bladder 
nearest  the  internal  meatus;  while  at  night,  when  he. is  sleeping,  it  would  fall 
away  from  the  posterior  wall  of  the  bladder  and  the  patient  would  be  compara- 
tively comfortable.  The  shape  and  surface  of  the  calculus  influences  frequency, 
as  calculus  with  a  smooth  surface  that  does  not  come  in  close  contact  with  the 
internal  meatus  produces  a  less  degree  of  frequency. 

Vesical  tuberculosis  resembles  closely  vesical  calculus  in  the  day  frequency, 
excepting  that  the  stream  is  not  interrupted,  as  it  often  is  when  stone  is  present ; 
but  at  night  the  frequency  continues  in  about  the  same  degree.  The  frequency 
in  this  disease  is  very  great  when  there  is  an  ulcer  near  the  internal  meatus  and 
consequently  over  the  vesical  sphincter ;  whereas,  when  ulcers  are  farther  away 
from  it,  the  urgency  is  much  less  marked.  In  vesical  tuberculosis,  before  ulcers 
have  formed,  the  frequency  is  not  so  great. 

Vesical  tumor  does  not  usually  cause  such  marked  frequency  as  either  cal- 
culus or  tuberculosis,  as  it  is  not  generally  situated  near  the  vesical  outlet. 

In  all  three  of  these  conditions,  there  is  congestion,  in  the  first  due  to  the 
irritation  of  the  stone,  in  the  second  about  the  tubercular  deposits  and  in  the 
third  in  and  about  the  tumor.  In  all  these  conditions,  the  closer  the  contact 
of  the  pathogenesis  with  the  internal  meatus,  the  more  marked  the  frequency. 
The  symptoms  are  also  more  severe  after  a  cystitis  has  developed. 

Impediments  to  urination  also  give  rise  to  frequency  in  different  ways  and 
in  different  degrees. 

When  a  bladder  has  to  force  urine  through  a  canal  in  which  there  is  a  nar- 
rov.'ing  in  some  locality,  or  where  its  shape  has  become  changed  through  pres- 
sure, an  extra  strain  is  brought  upon  it  and  consequently  an  extra  amount  of 
blood  is  brought  to  its  walls,  resulting  in  congestion.  If  this  inqiediment  is 
temporary,  the  bladder  quickly  regains  its  normal  condition,  after  it  has  sub- 
sided, and  the  frequency  is  consequently  of  short  duration  and  of  a  varied  de- 


242  SPECIAL   URINARY   SYMPT0:MS 

gree.  Tf  the  impediment  is  slight  at  the  start  and  increases  slowly,  then  the 
bladder  becomes  accustomed  to  it  and  slowly  hypertrophies ;  tlie  congestion  is 
then  not  marked  and  the  frequency  develops  slowly  and  insidiously.  If  the 
impediment  interferes  with  the  in-ination  to  such  a  degree,  owing  to  a  mechan- 
ical obstacle  or  a  weakened  state  of  the  bladder  wall,  that  the  bladder  cannot 
completely  empty  itself  and  a  certain  amount  of  residual  urine  is  always  pres- 
ent, occupying  a  part  of  the  bladder  space,  then  the  remainder  of  the  space 
for  the  transient  urine  is  consequently  lessened  and  the  patient  must  urinate 
more  frequently  on  account  of  this  diminished  space  being  filled  more  fre- 
quently. 

Temporary  impediments  to  urination  are  due,  first,  to  an  acute  prostatitis, 
principally  of  the  parenchymatous  form ;  next,  to  that  of  the  follicular  type, 
or  to  an  abscess  resulting  from  either  of  these  forms,  or  to  a  chronic  prostatitis. 
In  an  acute  parenchymatous  prostatitis,  when  one  or  both  lobes  are  involved, 
the  inflamed  gland  grows  up  into  the  prostatic  urethra,  toward  the  bladder,  the 
same  as  in  prostatic  hypertrophy.  This  gives  rise  to  frequency  of  urination  on 
account  of  the  inflammation  near  the  bladder  neck,  and  also  on  account  of  the 
residual  urine  resulting  from  the  impediment  itself  and  the  consequent  dimin- 
ished transient  capacity  of  the  bladder.  If  the  prostatitis  is  follicular,  then 
there  is  simj^ly  a  bulging  into  the  urethra  of  a  sufficient  degree  to  give  fre- 
quency, due  to  an  increased  strain  being  brought  upon  the  bladder  to  pass  the 
urine  through  the  narrowed  canal.  In  either  of  these  conditions,  an  abscess 
may  form,  giving  rise  to  an  increased  effort  of  the  bladder  to  force  urine  by 
the  impediment,  to  residual  urine  or  even  to  complete  retention.  When  the 
inflammation  subsides  or  the  abscess  breaks  or  is  evacuated,  the  frequency  dis- 
appears or  subsides.  If  it  disappears,  the  disease  is  probably  cured ;  but  if  it 
subsides  and  the  urine  is  not  clear  or  shreds  are  j)resent  or  prostatic  leakage, 
then  the  disease  is  not  cured  and  the  slight  frequency  remaining  is  the  result 
of  a  chronic  prostatitis. 

In  tuberculosis  of  the  prostate,  there  is  frequency  in  a  varied  degTee  due 
to  the  associated  prostatitis  and  urethritis.  This  is  more  marked  if  it  extends 
to  the  bladder.     When  confined  to  the  prostate  alone,  in  time  it  usually  subsides. 

In  prostatic  calculus,  the  frequency  also  varies  in  degree  and  is  often  very 
marked,  due  to  an  associated  i^rostatitis  and  sometimes  to  incomplete  retention. 
This  subsides  slowly  after  the  stone  has  been  removed. 

Exudates  about  the  urethra  in  any  part  w^hich  may  or  may  not  result  in  a 
periuretJnril  ahscess,  often  give  rise  to  temporary  frequency  of  urination,  due 
to  the  narrowing  from  the  outside  pressure,  which  disappears  when  the  abscess 
has  been  incised  or  broken.  If  tliere  is  great  pressure  in  the  urethra  in  these 
cases,  there  may  be  comj^ilete  retention  of  urine. 

Posterior  urethritis  occurring  during  an  attack  of  acute  urethritis  will  also 
give  rise  to  frequency,  often  in  a  very  marked  degree. 


DTSTFKBANCES    OF    MTCTTJRITTON  243 

It  is  easy  to  imderstand  llic  inoelianisni  of  frequency  of  uriiuitioii  in  acute 
posterior  urethritis.  Normally,  the  pressure  of  a  few  drops  of  urine  in  the 
posterior  urethra,  as  the  result  of  a  slight  leakage  through  the  sphincter  when 
the  bladder  is  sufficiently  distended,  is  said  to  be  the  real  cause  of  the  desire  to 
urinate.  The  desire  to  urinate  is  a  physiological  phenomena,  initiated  by  a  cen- 
ti'iiK'tal  irritation  of  the  posterior  urethra  and  the  neck  of  the  bladder,  by  a 
small  (piantity  of  urine.  When  the  posterior  urethra  is  inflamed,  the  irritability 
of  its  mucous  membrane  is  increased  to  a  high  potential  and  thus  the  patient 
is  obliged  to  pass  water  frequently. 

Frequency  of  urination  slowly  increasing  is  caused  by  a  chronic  impediment 
to  urination,  as  in  the  case  of  stricture  or  prostatic  hypertrophy. 

A  sfridure  may  be  congenital,  acquired  or  traumatic,  and  the  nearer  to  the 
bladder  it  is  situated  the  more  marked  Avill  be  the  frequency.  Congenital 
strictures  are  usually  linear  and  situated  at  the  meatus  or  just  in  front  of  the 
fossa  navicularis.  The  frequency  of  urination  in  children  is  principally  due 
to  this  condition  and  there  is  generally  a  history  of  nocturnal  incontinence. 
If  these  patients  develop  a  urethral  inflammation,  the  frequency  becomes  more 
marked. 

Acquired  strictures,  resulting  from  a  urethral  infection,  are  the  most  fre- 
quent. The  frequency  in  these  cases  until  the  stage  "when  residual  urine  begins, 
is  due  to  vesical  congestion  or  cystitis,  usually  the  latter.  The  frequency  is  more 
nuirked,  in  proportion,  during  the  day  than  during  the  night,  and  increases 
after  dissipation  or  exposure. 

Traumatic  stricture  is  due  to  a  fall  and  the  pressure  of  the  urethra  between 
the  triangular  ligament  of  the  pubis  and  the  impinging  body.  This  is  often 
severe,  giving  rise  to  retention  and  later,  perhaps,  to  overflow  incontinence, 
or  to  extravasation  of  urine.  In  cases  of  moderate  degree  with  no  com- 
plications, however,  a  mild  but  steadily  increasing  frecpiencv  will  probably 
result. 

Impediment,  with  residual  urine,  causes  frequency  of  urination  by  the 
vesical  congestion  resulting  from  the  impediment,  and  also  on  account  of  the 
lessened  bladder  space  for  the  transient  urine,  due  to  so  much  of  the  bladder 
cavity  being  taken  up  by  the  residual.  The  frequency  will  continue  to  increase 
in  proportion  to  the  amount  of  bladder  space  that  becomes  occupied  by  the 
residual  urine,  and  often  initil  complete  retention  or  overflow  incontinence 
results. 

In  prostatic  hypertrophy,  the  frequency  occurs  in  the  same  way  as  it  does 
in  cases  of  acquired  stricture  and  is  at  first  duo  to  congestion  from  the  extra 
amount  of  work  thrown  upon  the  bladder  in  its  effort  to  overcome  the  obstruc- 
tion. As  the  prostate  increases  in  size  and  the  venous  return  flow  from  the 
l)Uiddcr  is  interfered  with,  a  passive  congestion  takes  place.  This  is  more 
marked  at  nialit :  for  then  the  circulation  is  less  active  than  durino-  the  dav  when 


244  .     SPECIAL    URIXARY    SYMPTOMS 

the  patient  is  up  and  about.  The  more  marked  frequency  at  night  thus  differs 
from  the  frequency  of  stricture.  Later,  as  the  prostate  continues  to  increase  in 
size  and  pushes  up  into  the  bhidder,  the  residual  urine  increases,  and,  as  the 
bladder  is  more  encroached  upon  by  it,  the  space  for  the  transient  urine,  therc^ 
fore,  is  consequently  diminished  and  frequency  increases.  This  increased  fre- 
quency increases  as  in  stricture,  until  complete  retention  or  overflow  incon- 
tinence takes  place. 

In  prolapse  of  the  uterus,  cystocele  and  vaginal  hernia,  there  is  also  a  poucli 
of  the  posterior  wall  of  the  bladder,  giving  rise  to  residual  urine  and  conse- 
quently less  room  for  the  transient  urine ;  the  patient,  therefore,  passes  urine 
more  frequently,  just  as  he  would  in  case  of  prostatic  hypertrophy. 

(3)  Feequency  of  IlRiNATioisr  Due  to  Disease  Outside  of  the  Uri:n^art 
Tract  Interfering  w^th  its  Function. — First  among  these,  are  the  injuries 
and  diseases  of  the  spinal  cord  and  brain  (usually  the  latter),  as  the  sclerosis 
or  tumors  press  upon  them,  increasing  pressure  slowly  and  causing  an  inter- 
ference with  their  circulation. 

Here  the  innervation  of  the  bladder  is  interfered  with,  there  is  loss  of 
power  in  its  wall,  the  desire  is  not  so  imperative,  but  the  patient  feels  the  neces- 
sity of  passing  urine  more  frequently  in  order  to  avoid  dribbling  of  urine.  This 
increased  frequency,  the  result  of  mental  calculation,  increases  until  there  is  a 
larger  amount  of  residual  urine  and  a  consequent  overflow  retention. 

Interference  from  without,  when  there  is  no  disturbance  of  the  innervation 
of  the  bladder,  is  due  to  the  pressure  or  pulling  of  some  perivesical  tissue  with 
which  it  is  in  close  relation  or  to  which  adhesions  have  formed. 

Seminal  vesiculitis  causes  frequency  w'hen  the  vesicles  are  enlarged,  tense, 
acutely  inflamed  or  adherent  to  the  bladder.  The  seminal  vesicles  are  at  times 
very  large,  the  size  of  the  finger,  which  gives  rise  to  a  sense  of  fullness  of  the 
bladder  when  a  small  amount  of  urine  has  accumulated  in  it.  At  other  times, 
the  tense  feeling  of  the  seminal  vesicles  is  transmitted  to  the  bladder,  which 
lies  in  front  and  above  them.  Adhesions  to  the  bladder,  if  the  walls  of  the 
vesicles  are  thick  and  inelastic,  give  rise  to  a  sense  of  discomfort  when  the 
bladder  is  stretched  a  little.  In  these  cases,  the  feeling  of  discomfort  or  fullness 
is  transmitted  to  the  suprapubic  region.  The  frequency  in  seminal  vesiculitis, 
as  in  stricture  and  stone,  is  more  marked  in  the  day  than  in  the  night. 

The  uterus,  when  misplaced,  causes  frequency  of  urination.  This  is  espe- 
cially annoying  when  it  is  displaced  forward  in  such  a  way  as  to  rest  on  the 
bladder,  and  by  its  position  causes  a  feeling  of  discomfort  to  such  a  degree,  when 
a  small  amount  of  urine  has  accumulated  in  it,  that,  in  order  to  be  relieved, 
the  patient  must  empty  the  bladder. 

Again,  when  the  uterus  has  fallen  back  and  pulls  the  bladder  with  it,  there 
is  a  feeling  of  discomfort  from  pressure  on  the  pelvic  plexus  of  nerves,  from 
interference   with    the    function   of   the    bladder,    and    perhaps    from    residual 


DISTURBANCES    OF    MICTURITION 


245 


urine  that  accumulates  in  the  back  of  the  bladder,   resulting  in  a  desire  to 
urinate. 

An  inflammation  of  the  tubes  also  interferes  with  the  function  of  the  blad- 
der, through  holding  it  to  one  side  by  adhesions  and  interfering  with  its  dilata- 
tion and  contraction,  and  consequently  causing  frequency. 

An  exudate,  infiltration  or  abscess,  due  to  a  pus  tube  or  to  a  torn  or  septic 
uterus,  may  press  upon  the  bladder  from  without  so  as  to  prevent  it  from  dilat- 
ing, except  to  a  limited  degree,  and  thus,  by  diminishing  its  capacity,  neces- 
sitate voiding  wdien  but  a  small  quantity  is  present. 

Tumors  in  the  pelvis  pressing  upon  the  bladder,  on  account  of  their  weight, 
shape  or  size  thus  interfering  with  its  dilatation,  may  give  rise  to  frequency. 
This  condition  creates  a  sensation  of  fullness  before  the  bladder  is  actually  full, 
or  it  may  be  that  pressure  only  allows  the  bladder  to  fill  partially.  Instances 
of  this  are  fibroids  of  the  uterus,  hydatid  in  the  recto-vesical  space  and  appen- 
diceal abscess  in  the  pelvis. 

Cancer  of  the  uterus,  involving  the  bladder  wall,  may  also  give  rise  to  fre- 
quency of  urination,  through  the  congestion  it  causes ;  through  interfering  with 
the  vesical  contractibility ;  through  the  infiltration  of  its  wall ;  or  through  the 
irritation  of  an  ulcerating  area. 

Malignant  tumors  of  the  rectum  produce  much  the  same  result. 

A  loop  of  atonic  dilated  sigmoid,  in  case  of  fecal  retention  or  a  sigmoiditis, 
may  press  upon  the  bladder  sufficiently  to  give  rise  to  frequency  or  even  to  re- 
tention. This  is  a  much  more  frequent  cause  than  is  generally  realized.  In 
women,  this  loop  is  often  caught  dow^n  and  held  by  adhesions  resulting  from 
salpingitis. 

The  omentum,  when  adherent  to  the  bladder,  may  pull  it  in  any  direction, 
thus  interfering  with  its  function.  This  is  generally  due  to  pelvic  inflammation 
starting  as  a  salpingitis.  It  may  also  pull  other  tissues  or  organs  against  the 
bladder, 

TABLE  OF  FREQUENCY  OF  URINATION 

A,   Causes  Independent  of  Diseases  of  the  Urinary  Tract 


Temperature 


Mental 
emotions 


In  hot  weather,  due  to  prolonged  bathing  in  cold  watei,*. 

In   autumn,   due   to   diminished   perspiration   and   extra   work 

thrown  on  the  kidneys. 
In  winter,  due  to  wetting  of  the  feet,  chilling  of  the  extremities. 
In  spring,  when  the  sudden  active  perspiration  begins,  it  is  due 

to  concentrated  urine  charged  with  irritant  properties. 
Fear,    anxiety,    excitement,    or    thoughts    regarding    urinary 

troubles  or  brought  about  by  clinical  or  literary  work  on  the 

subject. 


246 


SPECIAL   URINARY    SYMPTOMS 


Diet 


Polyuria 


Vesical 

congestion  or 

cystitis 


Interference- 
temporary 


Urethral 


Interference- 
slowly 
increasino- 


Condiments,  mineral  waters,  alcoliolic  drinks. 
Certain  vegetables  giving  rise  to  intestinal  fermentation. 
Too  much  meat  giving  rise  to  intestinal  putrefaction. 
The  faulty  metabolism  from  this  diet  giving  rise,  through  in- 
dicanuria,  uricacidemia,  oxaluria  and  diabetes,  to  renal  irri- 
tation. 

Diseases  of  ]\Ictabolism : — Diabetes  insipidus  and  mellitus. 
IsTervous  Disorders : — Hysteria,  neurasthenia  and  hypochondriasis. 

B.  Dependent  on  Diseases  of  the   Urinary  Tract 

Interstitial  nephritis. 

Tubercular  nephritis. 

Calculous  nephritis. 

Movable  kidney  (temporary  polyuria). 

Vesical  calculus. 

Vesical  tuberculosis. 

Vesical  tumor. 

Prostatic  impediment. 

Urethral  impediment. 

Parenchymatous  prostatitis. 

Follicular  prostatitis. 

Suppurative  (abscess)  prostatitis. 

Chronic  prostatitis. 

Tubercular  prostatitis. 

Calculous  prostatitis. 

Acute  posterior  urethritis. 

Exudates  about  the  urethra. 

Urethral  calculi. 

Periurethral  abscess. 

Stricture,  frequency  due  to  vesical  congestion  or  inflammation 
until  residual  urine  begins. 

Prostatic  hypertrophy,  due  to  vesical  congestion  or  inflamma- 
tion until  residual  urine  begins. 

Stricture  and  prostatic  hypertrophy,  due  to  lessened  bladder 
space  to  hold  the  transient  urine  after  residual  urine  has 
begun  to  be  present. 

Prolapse  of  uterus,  due  to  lessened  bladder  space  to  hold  the 
transient  urine. 

Vaginal  hernia,  due  to  lessened  bladder  space  to  hold  the  tran- 
sient urine. 

Cystocele,  dne  to  lessened  bladder  space  to  hold  the  transient 
urine. 


Interference 

with  residual 

urine 


DISTURBANCES    OF   MICTURITION 


247 


C.  Dependent  on  Diseases  Outside  of  the  Urinary  Tract  Interfering  with  its 

Function 


Interference — 
temporary 


Interference- 
slowly 
increasing 


Interference 
with  residual  • 
urine 


'  Seminal  vesiculitis. 

Salpingitis. 

Abscess,  exudates,  infiltrates. 
,  Appendiceal  abscess. 
'  Hydatid  cyst  of  pelvis. 

Tumor  of  rectum. 

Sigmoiditis  or  sigmoid  retention, 

Displaced  uterus. 

Uterine  fibroids. 

Sclerosis  of  the  cord 


Tabes  dorsalis. 
Lateral  sclerosis. 
Tabes  dorsalis. 
Lateral  sclerosis. 
Injuries  and  diseases  of  the  brain. 


Sclerosis  of  the  cord 


Consecutive  Cases  of  Feequency  of  Urination. — In  2-iO  cases  coming 
to  my  clinic  during  the  winter  of  1907,  frequency  was  found  to  be  due  to  a 
single  cause  in  127  cases.  Mixed  causes,  namely,  two  or  more  pathological  con- 
ditions tending  by  their  combined  action  to  cause  this,  occurred  in  113  cases. 


List  1 

Cases  of  frequency  in  which  a  single  condition 
was  found  as  a  cause  at  the  time  of  the  visit. 

Urethritis 46 

Stricture 25 

Prostatitis  (including  1  case  of  tuberculosis)  23 
Seminal  vesiculitis  (including  1  case  of  tuber- 
culosis)      10 

Cystitis  (including  3  tubercular) 7 

Prostatic  hypertrophy 5 

Movable  kidney 2 

Tumor  of  bladder 2 

Stone  in  bladder 2 

Contracted  bladder  (frequency  from  dimin- 
ished capacity) 1 

Dilated  bladder  (transient  capacity  or  di- 
minished space  left  for  urine  over  the 
amount  of  residuum) 1 


List  2 
Cases  of  frequency  in  which  a  number  of 
pathological  conditions  were  found  as  contributing 
causes  at  the  time  of  the  visit. 

Urethritis 43 

Stricture 38 

Prostatitis  (including  2  cases  of  edema  and 

2  cases  of  tuberculosis) 80 

Vesiculitis    (including  2  cases  of  perivesic- 

ulitis)  73 

Cystitis 46 

Prostatic  hypertrophy 6 

Prostatic  abscess 5 

Tumor  of  bladder 3 

Nephritis 5 

Pyelitis 4 

Pyelonephritis 3 

Renal  calculus 3 

Ulcer  of  bladder 1 

Sarcoma  of  prostate 1 

Note. — In  looking  at  this  table,  we  will  see  that  urethritis  was  present  in  89  cases  of  frequency, 
stricture  in  63  cases,  cystitis  in  53  cases,  prostatic  hypertrophy  in  but  11  cases,  while  prostatitis 
was  present  in  103  cases  and  vesiculitis  in  93  cases.  This  can  be  explained  by  saying  that  ure- 
thritis, stricture,  cystitis,  and  prostatic  hypertrophy  are  the  principal  active  causes  of  frequency; 
whereas,  prostatitis  and  vesiculitis,  excepting  in  the  real  acute  attacks  or  in  tubercular  cases,  are 
usually  contributory  causes.     This  list  was  compiled  by  Dr.  Nelson  of  Cincinnati, 


248  SPECIAL   URINARY    SY:\IPT0:\IS 

In  the  list  of  cases  in  Avliicli  we  could  ascribe  the  frequency  to  one  cause,  the 
largest  number  occurred  in  the  following  order :  Urethritis,  stricture,  prostatitis, 
seminal  vesiculitis,  cystitis  and  prostatic  hypertrophy ;  whereas,  in  the  remain- 
ing cases,  there  was  no  marked  number  under  any  one  disease.  Of  the  com- 
bined causes,  we  will  also  see  that  these  six  conditions  were  more  or  less  present 
in  the  majority  of  the  cases.  This  list  embraces  2-1:0  consecutive  cases  of  fre- 
quency coming  to  the  clinic  during  the  -winter  session. 

In  my  hospital  work,  the  causes  are  different  singly  and  combined ;  stricture 
is  the  most  common  cause,  next  acute  prostatitis,  posterior  urethritis,  vesical 
tuberculosis,  vesical  calculus  and  prostatic  hypertrophy. 

Of  these,  stricture,  prostatic  hypertrophy,  vesical  tuberculosis  and  vesical 
calculus  are  generally  accompanied  by  cystitis,  while  acute  prostatitis  and  pos- 
terior urethritis  are  usually  complications  of  acute  anterior  urethritis. 

Treatment  of  Frequency  of  Urination. — Treatment  of  frequency  of  urina- 
tion varies  largely  according  to  the  cause,  and  is  considered  in  the  various  chap- 
ters dealing  with  each  of  the  conditions  involved.  This  leaves  but  few  words  to 
be  said  regarding  the  general  treatment  of  functional  frequency  of  micturition. 

It  is  imjDortant  to  keep  the  feet  warm  and  dry  during  the  fall  and  winter, 
to  increase  the  clothing  in  accordance  with  the  temperature  of  the  air.  All 
excitement  which  would  tend  to  cause  local  irritation  should  be  avoided.  The 
diet  should  be  simple  mixed  animal  and  vegetable,  taking  a  small  amount  of  a 
variety  of  food  rather  than  a  large  amount  of  any  one  kind.  Uried  foods  and 
sweets  should  be  j)artaken  of  sparingly.  Condiments,  salted  and  pickled  food, 
should  be  avoided.  Alcoholics  should  be  avoided  or  restricted.  Spirits,  ale, 
beers  and  champag-ne,  are  the  worst  drinks,  whereas  red  wines  are  the  least 
harmful.    About  three  pints  of  water  should  be  taken  in  twenty-four  hours. 

In  the  therapeutic  line,  hot  Turkish  baths  should  be  taken  twice  a  week,  hot 
sitz  baths  before  retiring.  If  there  is  any  fecal  retention  or  trouble  witli  the  pros- 
tate gland  or  seminal  vesicles,  hot  rectal  douches  are  better  than  hot  sitz  baths. 

Massage  of  the  prostate  and  vesicles  is  of  value  in  diseases  of  these  organs, 
unless  they  are  tubercular. 

If  the  urine  is  very  acid,  alkalines  should  be  given,  preferably  acetate  or 
citrate  of  potash.  Of  the  mineral  waters,  the  most  satisfactory  in  my  judg- 
ment is  Celestine  vichy.  If  much  pus  is  present,  urotropin,  salol,  benzoic  acid 
and  benzoate  of  soda,  are  the  best  urinary  antiseptics.  If  there  is  acute  inflam- 
mation, santal  oil  is  the  best. 

For  relieving  the  frequency,  especially  if  spasm  is  present,  the  antispas- 
modics, as  belladonna  and  hyoscyanms,  codein,  morphin  and  the  bromids  are 
the  best. 

For  bladder  irrigation,  solutions  of  boric  acid,  nitrate  of  silver  or  protargol 
are  the  best.  Tor  bladder  injections,  small  quantities  of  argyrol,  ten  to  twenty- 
five  per  cent,  gommenol  or  iodoform  emulsion,  are  the  most  efficacious. 


DISTT^^BANCES    OF  1\rTrTFKITIOX        "  249 

Tlie  bowels  slidiild  Itc  kept  npcii  by  cascara  sagrada,  salines,  such  as  phos- 
phate of  soda,  Apeiita  or  some  mild  mineral  laxative  waters,  and  should  be  as- 
sisted if  necessary  by  glycerin  sn])])ositories  or  rectal  enemas. 

Moderate  exercise  should  be  taken. 

Dysuria  ok  Isciiukia 

Dysuria,  or  ischuria,  is  a  term  which,  Avhcn  correctly  used,  ajjplics  to  dif- 
ficulty in  voiding  urine  and  may  be  accompanied  by  pain  and  a  spasmodic  condi- 
tion of  the  bladder  at  its  neck,  known  as  tenesmus.  Dysuria  does  not  mean 
painful  micturition,  pure  and  simple.  Just  as  dyspepsia  stands  for  an  inabil- 
ity to  digest  food,  so  dysuria  stands  for  a  difficulty  to  pass  the  water. 

Dysuria  may  occur  suddenly  as  an  unforeseen  event ;  for  example,  when  a 
stone  becomes  jammed  in  the  neck  of  the  bladder  or  Avhen  a  papilloma  of  the 
bladder  suddenly  twists  in  such  a  way  as  to  block  the  orifice.  In  other  condi- 
tions, as,  for  example,  in  hypertrophied  prostate,  in  tumors  of  the  prostate 
and  in  strictures  of  the  urethra,  dysuria  often  conies  on  gradually,  the  difficulty 
in  passing  water  becoming  more  and  more  pronounced. 

In  the  milder  forms  of  dysuria,  the  act  of  urination  is  merely  accompanied 
by  a  slight  amount  of  exertion  in  which  the  accessory  muscles,  the  abdominal 
and  the  perineal,  are  brought  into  action.  In  severe  forms,  the  individual  may 
be  unable  to  pass  water,  except  in  certain  positions,  as  squatting  or  leaning  over 
and  bracing  against  stationary  objects.  In  these  severe  cases,  the  face  may  be- 
come agonized,  red  with  swollen  veins  ;  pers]3iration  appears  in  beady  droj^s  on  the 
forehead,  the  breath  is  held  and  the  lips  are  compressed  in  the  effort  at  expulsion, 
which  is  repeated  periodically  with  intervals  of  rest  and  is  accompanied  often 
by  an  involuntary  discharge  of  gas  and  feces.  When  the  patient  is  in  the  squat- 
ting position,  a  prolapse  of  the  rectum  of  two  inches  or  more  may  take  place. 

This  is  the  clinical  description  of  the  symptom  dysuria  as  such.  Of  course, 
a  number  of  other  disturbances  of  micturition  and  of  allied  clinical  signs  are 
very  frequently  associated  wdth  this  particular  manifestation. 

Among  these,  frequency  of  micturition,  retention  and  overflow  incontinence, 
pain  during,  before  and  after  the  act  of  urination  may  be  grouped  in  a  syn- 
drome, each  element  of  which  can  be  analyzed  and  set  down  by  itself  as  having 
its  own  significance. 

Dysuria  being  present,  the  question  arises  to  what  cause  it  should  be  at- 
tributed ?  Our  first  thought,  of  course,  will  be  the  presence  of  some  obstruc- 
tion which  prevents  a  free  and  normal  outlet  of  the  stream.  The  chief  causes 
of  such  an  obstruction  have  already  been  mentioned.  They  are  stricture  of  the 
urethra ;  prostatic  hypertrophy ;  stones  in  the  bladder  or  the  urethra  ;  tumors 
of  the  bladder  or  the  prostate ;  or  acute  inflammatory  swelling  of  the  mucous 
membrane  of  the  neck  of  the  bladder  or  the  prostatic  urethra. 

A  form  of  dvsuria   depending  only  upon   a   spasmodic  contraction  of  the 


250  SPECIAL   rlllXARY    SYMPTOMS 

sphincter  may  bo  styled  a  nervous  dysnria.  It  may  ho  followed  later  hy  in- 
continence and  is  characterized  hy  an  ahsence  of  all  local  evidences  of  disease 
of  the  urinary  organs.  Whenever  such  adysuria  is  present,  a  suspicion  arises 
as  to  the  j)resence  of  a  spinal  disease. 

Dysuria  of  inflammatory  origin  is  simple  in  its  mechanism,  depending  upon 
the  congestion  and  swelling  of  the  parts,  and  is  usually  fairly  easy  to  recognize 
by  the  history  and  symptoms.  In  the  presence  of  an  acute  urethritis,  the  onset 
of  dysuria  with  painful  and  frequent  micturition  is  the  signal  of  the  involve- 
ment of  the  jDOsterior  urethra.  It  occurs  in  an  intense  degree,  especially  if  ac- 
companied by  fever,  when  an  acute  involvement  of  the  prostate  should  be  feared, 
unless  excluded  by  rectal  examination.  When  dysuria  and  other  disturbances 
of  micturition  occur  in  tlie  course  of  a  chronic  urethritis,  we  are  led  to  suspect 
stricture.  If  the  patient  is  advanced  in  age,  and  if  the  dysuria  has  been  coming 
on  gradualh',  increasing  apace  with  frequency  of  urination,  we  naturally  look 
for  hypertrophy  of  the  prostate.  A  characteristic  of  the  dysuria  of  prostatics  is 
that  the  symptom  is  aggravated  at  night.  Rest  in  bed,  a  horizontal  position  of 
the  pelvis,  a  sedentary  life  and  the  presence  of  constipation,  are  all  factors 
Avhich  increase  the  dysuria  of  prostatics. 

One  of  the  most  interesting  forms  of  dysuria  is  that  due  to  stone  in  the 
bladder.  In  this  form,  patients,  instead  of  being  aggravated  when  lying  in  bed, 
are  relieved  by  the  horizontal  position,  while  the  upright  position  and  any  jars 
or  jolts,  as  in  walking  or  running,  in  which  the  stone  has  a  chance  to  become 
lodged  in  the  vesical  orifice,  increases  the  discomfort. 

A  temporary  dysuria  frequently  occurs  after  urethro-vesical  instrumenta- 
tion— as  after  the  passage  of  a  cystoscope,  sounds,  or  other  dilating  instruments 
—and  after  irrigations  by  the  Janet  method,  or  deep  instillation  of  strong  solu- 
tions of  silver  nitrate.  This  should  be  termed  a  false  dysuria,  as  it  is  simply 
due  to  irritation  and  not  to  a  pathological  condition,  and  is  usually  of  very 
brief  duration. 

All  varieties  of  dysuria  are  frequently  accompanied  by  more  or  less  pain, 
or  at  least  by  a  sensation  of  pressure  and  burning  which  is  quite  distinct  from 
that  of  an  exaggerated  desire  to  urinate.  The  latter  is  a  sensation  of  pressure 
or  burning,  which  cannot  exactly  be  called  a  pain,  in  fact,  can  scarcely  be  anal- 
yzed, yet  it  forms  part  and  parcel  of  the  mixed  sensations  experienced  by 
patients  afflicted  with  dysuria.  In  certain  conditions,  the  contraction  of  the 
bladder  walls  in  trying  to  overcome  the  obstacle,  whatever  that  may  be,  gives 
rise  to  a  colicky  pain.  This  vesical  colic  may  be  an  accompaniment  of  dysuria. 
It  is  characterized  usually  by  a  gTadual  onset,  a  rapid  rise  to  a  climax,  followed 
by  a  remission.  Usually  it  is  located  in  the  body  of  the  bladder,  accompanied 
by  intense  desire  to  urinate,  and  may  radiate  to  the  perineum,  the  rectum  or 
the  urethra,  or  into  the  hypogastrium,  the  groin,  or  even  the  loin. 

Vesical  colic  is  an  accompaniment  also  of  retention,  especially  of  the  acute 


DISTURBANCES    OF    MTCTTTRTTTON 


251 


form.  It  is  dwc  to  Iroiihlos  aecf)iii]iiini(M|  liy  residual  iiriiic,  to  lesions  seated  in 
the  upper  zone  of  the  bladder  or  to  that  covered  by  })eritoneuni ;  to  deep-seated 
lesions  and  to  perivesical  troubles. 


Bladder 


Extra- 
vesical 
causes 


Prostate 


\"esical  tumors  < 


CONDITIONS    GIVING    KISE    TO    DYSURIA 

''Vesical  calculus,  especially  if  it  obstructs  the  neck  of  the  bladder. 
Papillomas,  if  they  obstruct  the  vesical  neck. 
Intiltrated  or  malignant,  if  they  interfere  with, 
dilatation  and  contraction  of  the  bladder. 
Acute   inflammation   of  the  bladder  neck,   the  congestion  of  the 
mucous  membrane  imparting  the  sensation  that  the  bladder  is 
not  entirely  emptied. 

'  \^esiculitis. 
Appendicitis  with  bladder  adhesions. 
Salpingitis. 
'  Uterine  displacement. 

'  Uterine. 
Ovarian. 
Kectal. 
Hydatids. 
Inflammatory  exudates. 
Pressure  of  sigmoid. 

•  1  f  In  Retzius'  space. 

Abscess    J  ^ 


Inflanunation  outside 
of  the  bladder 


Extravesical 
pressure 


Pelvic  tumors    < 


Pelvic. 
Adhesions  of  omentum. 
Extravesical         -J  Adhesions  of  tubes. 

traction  Adhesions  of  large  intestines. 

'Calculus  in  prostate. 
Tumors  of  prostate.      r  Parenchymatous. 
Acute  prostatitis  J  Follicular. 

iHypertrophy.  [  Abscess. 

Calculus  in  any  part  of  the  urethra,  but  most  marked  in  the  pros- 
tatic portion. 
Acute  posterior  urethritis,  the  sensation  of  obstruction  being  due 

to  intense  congestion. 
^Stricture  accompanying  chronic  urethritis. 
Periurethral  exudates. 
Periurethral  abscess. 
Urinary  extravasation. 
Nervous  difficulty  due  to  lesions  of  the  spinal  cord. 


Urethra 


Extra- 
urethral 


252  SPECIAL   URINARY   SYMPTOMS 

Painful  Micturition 

Under  this  headino;,  we  shall  discuss  pain  which  either  precedes,  accompanies, 
or  follows  the  act  of  micturition.  This  symptom  is  of  the  greatest  imjjortance 
in  urological  diagnosis,  as  it  often  enables  us  to  localize  and  to  define  the  char- 
acter of  urinary  diseases. 

Micturition  is  made  jDainful  in  the  presence  of  congestion,  inflammation, 
ulceration,  new  growths,  calculi,  foreigTi  bodies  or  traumatism,  either  in  the 
bladder,  the  jDrostate  or  the  urethra. 

There  is,  however,  a  group  of  conditions  of  the  kidneys  and  the  ureter 
which  indirectly  give  rise  to  painful  micturition.  Of  these,  perhaps,  the  most 
prominent  is  due  to  stone  in  which  small  calculi  pass  down  the  ureter  and  stick 
just  above  or  at  the  opening  into  the  bladder,  giving  rise  to  a  sensation  akin  to 
those  in  the  bladder,  the  prostate,  or  the  urethra. 

Painful  micturition  is  a  prominent  accompaniment  of  cystitis.  In  the 
milder  degree,  especially  of  the  chronic  type,  it  is  not  very  pronounced.  In  the 
acute  form,  the  pain  is  very  distressing  and  the  same  may  be  said  of  the  tuljer- 
cular  form,  especially  when  accompanied  by  ulceration.  In  tumors  of  the 
bladder,  painful  micturition  is  also  one  of  the  important  symptoms,  becoming 
marked  when  the  new  growth  involves  a  large  portion  of  the  organ  and  Avhen  it 
ulcerates. 

Stones  or  foreign  bodies  in  the  bladder,  especially  if  they  be  rough  or 
pointed,  may  cause  intense  pain  during  the  act  of  micturition. 

The  rule  is,  so  far  as  the  time  of  occurrence  of  the  pain  is  concerned,  that, 
in  bladder  conditions,  the  acme  of  intensity  is  reached  at  the  end  of  the  act  of 
expulsion — that  is,  when  the  greatest  amount  of  vesical  contraction  takes  place. 

The  character  and  the  position  of  the  pain  during  micturition,  when  due  to 
bladder  conditions,  is  not  distinctive.  It  may  present  itself  as  a  tenesmus  or 
burning  sensation  at  the  neck  of  the  bladder,  or  it  may  be  located  in  the  hypo- 
gastrium,  radiating  to  the  end  of  the  penis,  the  groin  or  even  the  loin.  The 
pain  of  stone  in  the  bladder  is  characteristically  located  at  the  end  of  the  urethra. 

In  posterior  urethritis  and  in  inflammations  of  the  prostate,  painful  urina- 
tion, accompanied  by  dysuria,  and  frequency,  constitute  a  very  frequent  and 
important  set  of  symptoms.  Usually  the  pain  is  felt  at  the  beginning  of  urina- 
tion, when  the  posterior  urethra  is  distended  by  a  rush  of  urine.  The  contrac- 
tion of  the  posterior  urethra  at  the  end  of  micturition  causes  an  exacerbation 
of  the  pain  at  that  time. 

Painful  micturition  may  also  be  present  without  any  organic  affections  of 
the  urinary  organs,  when  the  character  of  the  urine  is  such  as  to  irritate  the 
lower  passages.  Among  these  conditions  may  be  mentioned  phosphaturia, 
oxaluria,  nricacidemia  and  other  conditions  in  which  there  is  an  excess  of  crys- 
talline elements  in  the  urine. 


DISTITKEANCES    OF    MICTURITION 


253 


(2)  Congestion  or  inflammation 
of  the  bladder  (cystitis) 
dne  to 


PAINFUL    MICTUKITION 

(!)    Ureter: — Calculus  near  or  at  the  opening  into  the  bladder. 

Vesical  calculus,  especially  if  rough 
or  pointed. 

Vesical  tuberculosis  with  ulcer  near 
the  urethral  opening. 

Vesical  tumor,  especially  when  ma- 
lignant or  ulcerating,  or  if  it  comes 
in  contact  with  the  urethral  open- 
ing. 

Vesical  ulcer. 

Impediment  from  below,  pressure 
from  without,  displacement  or  an 
interference  with  its  functions. 

Gonorrhea,   giving  rise  to   an   acute 

prostatitis. 
Tuberculosis. 
Calculus. 
Tumors   (especially  malignant). 

Gonorrhea      ^         •  m      •       i 
Jiispecially  m  the 

posterior   portion. 


(3)  Congestion  or  inflammation 
of  the  prostate  (prostati- 
tis) due  to 


(4)    Congestion   or   inflammation 
of  the  urethra  (urethritis) 


Stone 
Crystals 

For  treatment,  see  the  treatment  of  the  trouble  under  the  special  chapters. 


Changes  in  the  Urinary  Stream 

Changes  in  the  urinary  stream  include  alteration  in  the  shape,  caliber,  force 
and  rhythm  of  the  stream. 

The  form  and  direction  of  the  stream  is  altered  in  epispadias,  hypospadias, 
fistula,  abnormalities  of  the  meatus  and  other  anomalies.  There  are  certain 
changes  in  form  that  are  transient  and  depend  upon  the  gluing  of  the  meatal 
lips  by  discharge.  In  such  cases,  the  stream  may  be  twisted,  flattened  or  split 
for  a  few  seconds,  but  wdien  the  meatus  has  been  washed  by  it,  the  stream  again 
becomes  normal. 

Persistent  changes  in  the  form  of  the  stream  indicate  the  presence  of 
strictures.  They  may  consist  of  a  special  tM'isting,  a  flattening,  or  a  splitting 
of  the  stream  into  several  smaller  jets,  depending  on  the  distribution,  size,  or 
amount  of  thickening  forming  the  stricture.  In  stricture,  these  changes  may 
be  accompanied  by  difficulty  in  passing  water. 

The  caliber  of  the  stream  varies  greatly  according  to  the  size  of  the  meatus, 


254  SPECIAL   URINAET    SY]\rPTOMS 

i.  e.,  the  nozzle  tlirontih  wliicli  the  stream  iinist  ])ass.  If  tlie  iiientus  is  narrow, 
the  stream  is  fine,  hut  when  the  nieatns  is  normal  and  the  stream  is  very  small, 
the  presnmption  is  that  there  is  a  stricture  farther  back. 

The  force  of  the  stream  depends  npon  the  force  of  contraction  of  the  de- 
trusor muscle  of  the  bladder  and  tlie  amount  of  the  obstruction  or  interference. 
The  force  normally  depends  upon  a  variety  of  circumstances.  If  the  bladder 
muscle  is  tired  by  long  retention  in  normal  conditions,  the  stream  is  weaker. 
It  is  also  weaker  in  old  people.  Any  condition  which  injures  the  bladder  mus- 
cles or  interferes  with  free  circulation,  will  cause  the  force  of  the  stream  to  be 
diminished. 

The  stream  loses  its  force  in  a  variety  of  nervous  conditions,  notably  in 
scleroses  of  the  cord  (tabes  and  lateral  sclerosis),  and  in  other  diseases  of  the 
brain  and  cord  in  which  the  action  of  the  detrusor  is  impaired.  In  the  pres- 
ence of  any  obstruction  of  the  stream,  there  is  usually  a  period  of  compensa- 
tion at  first,  during  which  an  increased  muscular  action  overcomes  the  re- 
sistance, and  the  stream  remains  normal  in  force.  Later,  however,  an  atonic 
condition  of  the  bladder  develops  and  the  force  of  the  stream  is  diminished. 
This  is  especially  the  case  in  hypertrophy  of  the  prostate,  in  stricture  of  the 
urethra,  etc. 

In  prostatic  hypertrophy  the  bladder  wall  may  be  strong  and  the  urethra 
of  large  size,  as  is  evidenced  after  the  passage  of  a  large-sized  catheter  and  the 
escape  of  a  forceful  stream  of  urine  through  it,  and  yet  if  no  catheter  is  passed, 
the  prostatic  obstruction  will  be  found  sufficient  to  slow  and  diminish  the  force 
of  the  stream. 

The  force  of  the  stream  is  also  lessened  when  the  bladder  contractions  are 
interfered  with,  \vhere  there  are  adhesions  of  the  omentum,  tubes  or  intestines 
to  the  bladder,  displacements  of  the  uterus,  pressure  of  pelvic  tumors  and  inflam- 
matory exudates. 

The  rhythm  of  the  stream  means  its  normal  uninterrupted  flow,  beginning 
with  a  strong,  steady  stream  and  gradually  diminishing.  The  last  drops  are 
then  expelled  by  a  contraction  of  the  accessory  muscle.  In  old  people,  the  last 
part  of  the  act  is  considerably  less  forceful  and  the  same  may  occur  in  people 
who  retain  their  urine  for  a  long  time. 

Interruption  in  the  stream  of  urine,  known  sometimes  as  urinary  hesitancy, 
or  urinary  stammering,  occurs  in  a  variety  of  conditions.  These  include  many 
in  which  there  is  dysuria,  the  interruption  then  being  due  to  a  necessary  relaxa- 
tion of  the  auxiliary  muscles  of  micturition.  Another  cause  of  interruption 
of  the  stream  is  a  spasmodic  contraction  of  the  vesical  sphincter,  such  as  occurs 
in  acute  inflammations  in  and  about  the  neck  of  the  bladder,  as,  for  example, 
in  acute  prostatitis.  Finally,  the  stream  of  urine  may  be  interrupted  in  cases 
in  which  the  bladder  itself  is  free  from  disease,  as  in  spinal  diseases  in  which 
the  vesical  reflex  is  increased,  causing  a  contraction  of  the  sj^hincter  during  the 


DISTURBANCES    OF    MICTURITION  255 

act,  wliicli  interrupts  the  streniii.      Infiauiiiiations  of  tlie  rcctinn,  acting-  reflexly 
upon  the  bladder,  may  also  produce  the  same  effect. 

When  small  stones,  pediculated  growths,  or  tonguelike  projections  of  pros- 
tatic tissue  are  present,  the  stream  may  be  interfered  with. 

RETENTIOISr    OF    TJrINE 

This  term  designates  an  inability  on  the  part  of  the  bladder  to  empty  itself, 
because  of  loss  of  power  or  obstruction.  It  is  variously  classified  as  complete 
or  incomplete,  according  to  the  degree  of  retention ;  acute  or  chronic,  depending 
upon  the  duration  and  severity  of  the  attack ;  and  traumatic,  paralytic  or  ob- 
structive, referring  to  the  nature  of  the  cause. ^ 

Complete  retention,  from  whatever  cause,  is  a  condition  in  which  the  pa- 
tient cannot  pass  any  urine  from  the  bladder ;  it  is  incomplete  when  he  can 
empty  it  only  in  part,  a  certain  residuum  of  an  ounce  or  more,  remaining  in 
the  bladder.  The  urine  which  passes  represents  the  excess  over  this  residuum, 
or  the  transient  urine.  Acute  retention  occurs  when  the  patient  suddenly  finds 
that  he  cannot  pass  any  urine,  though  he  may  never  before  have  had  any  diflfi- 
cult}^  It  is  chronic  when  for  a  long  time  he  has  not  been  able  to  empty  his 
bladder )  and  paralytic  when  his  inability  to  void  urine  is  due  to  paralysis  of  the 
bladder  wall,  owing  to  disease  of  either  brain  or  cord. 

Retention  is  obstructive  when,  owing  to  some  growth  or  impediment  in  or 
about  the  neck  of  the  bladder  or  at  some  point  of  the  urethra,  either  no  urine 
or  not  all  of  it  can  be  forced  out.  It  is  traumatic  when  some  wound  gives  rise 
to  an  impediment,  either  within  the  urethra  itself  or  on  the  outside,  which 
presses  upon  it. 

Occasional  acute  attacks  of  retention  may  be  due  to  operations,  alcoholism, 
profound  temporary  stupor,  or  voluntary  refraining  from  urinating. 

The  loss  of  power  is  variously  referred  to  as  paralysis,  paresis  and  atony. 
There  is  really  very  little  difference  between  certain  degrees  of  these  conditions. 
Complete  paralysis  of  the  bladder  is  found  when,  on  account  of  some  brain  or 
cord  lesion,  it  is  incapable  of  expelling  any  urine;  partial  paralysis,  when  the 
bladder  is  not  able  to  empty  itself  fully.  Paresis  is  another  name  for  partial 
paralysis,  and  atony  is  a  condition  where,  through  lack  of  power,  the  bladder 
wall  cannot  force  out  all  the  urine.  Both  in  atony  and  paralysis,  the  bladder 
may  be  constantly  distended  by  urine  to  a  certain  extent,  perhaps  to  its  utmost 
limit,  as  a  passive  sac,_and  the  excess  of  this  residuum  may  dribble  away  in- 
voluntarily (overflow  incontinence)  ;  or  it  may  be  expelled  in  small  quantities 
by  repeated  acts  of  urination  in  the  ordinary  way,  accompanied  by  great  strain- 
ing and  assisted  by  the  voluntary  contractions  of  the  muscular  wall  of  the 
abdomen. 

'  Guiteras,  "Retention  of  Urine,"  A''.  Y.  Medical  Journal,  May  20-27,  1899. 


256  SPECIAL   URINARY    SYMPTOMS 

The  causes  of  atony  arc:  Ovcrdistcntion  Ly  neglecting  to  urinate,  invuliin- 
tary  retention  in  cases  of  fever  and  coma,  and  nretliral  obstructive  conditions. 
The  muscular  coat  of  the  bladder  may  be  paralyzed  from  any  cause  that  will 
induce  loss  of  muscular  power  in  other  parts  of  the  body,  and  the  paralysis  may 
aifect  either  the  detrusor  urina',  or  the  sphincter  vesica^  or  both  at  the  same 
time.  Power  may  be  diminished  or  wholly  lost,  and  this  impairment  of  func- 
tion may  be  temporary  or  permanent. 

The  muscles  of  the  bladder  which  expel  or  retain  the  urine  are  only  ]iai'tially 
under  control  of  the  will.  Thus  the  contraction  of  the  detrusor  is  involun- 
tary, being  occasioned  as  a  reflex  from  the  stimulus  of  the  urine  in  the 
bladder.  When  sensibility  is  diminished  and  the  presence  of  urine  no  lf)nger 
acts  as  a  stimulus  on  the  detrusor,  the  result  is  urinary  retention.  The  com- 
pressor urethras  must  relax  under  the  influence  of  the  will  before  the  contents 
of  the  bladder  can  escape. 

It  is  well  to  remember  also  that  the  bladder  muscle  may  be  directly  paral- 
yzed by  overdistention,  as  already  stated,  or  by  inflammation  extending  fr(jm 
either  its  mucous  or  its  serous  coat. 

Causes. — Acute  Retention. — Acute  or  temporary  retentions  may  be  due 
to  operations  on  or  about  the  external  genitals,  anus  or  rectu^ii,  or  upon  parts 
of  the  body  quite  distant  from  this  locality,  bringing  about  a  spasmodic  inability 
to  urinate.  It  may  also  be  due  to  acute  alcoholism ;  to  large  doses  of  opium, 
belladonna  or  hyOscyamus,  especially  when  given  by  rectum ;  or  to  profound 
temporary  stupor,  such  as  occurs  in  typhoid  fever  or  other  adynamic  diseases. 
Voluntary  refraining  from  urinating  until  the  bladder  is  so  full  that  its  walls 
are  unable  to  contract,  as  when  one  is  in  company  where  no  opportunity  is  af- 
forded, is  also  at  times  a  cause  of  retention.  It  may  also  be  found  in  pregnant 
women,  due  to  some  displacement  of  the  uterus,  which  presses  upon  the  bhuhh^'. 
If  it  occurs  after  delivery,  it  is  due  to  displacement  of  the  bladder  or  to  the 
effect  of  long  pressure  upon  its  neck  during  delivery. 

Acute  attacks  may  also  occur  during  chronic  obstructive  conditions,  such 
as  stricture  or  enlarged  prostate  from  various  causes. 

In  the  majority  of  cases,  retention  is  due -either  to  organic  nervous  lesions 
or  to  obstructions  involving  the  urethra  or  prostate. 

Chronic  Retention  (Complete  or  Incomplete). — Certain  organic  nervous 
diseases  cause  retention. 

In  paraplegia,  in  hemiplegia,  in  locomotor  ataxia  and  in  lateral  sclerosis, 
w^e  may  have  complete  or  partial  retention  due  to  motor  paralysis. 

In  Pott's  disease,  we  may  have  retention  with  incontinence,  due  to  paralysis 
by  interference  with  the  vesico-urethral  nerve  centers. 

In  injuries  of  the  brain  and  spinal  cord  the  same  applies.  These  are  at- 
tended by  important  changes  in  the  urinary  system  as  well  as  in  the  urine. 
These  changes  do  not  seem  to  be  connected  with  the  particular  locality  of  the 


DISTURBANCES    OF   MTCTITRTTTON  267 

injury.  They  occur  almost  uiiifonnly,  wlicther  the  injury  affects  the  Inmbar, 
the  dorsal  or  the  cervical  region. 

In  the  varions  forms  of  spinal  sclerosis,  there  may  be  more  or  less  complete 
retention,  in  tlie  earlier  stages  of  a  spasmodic  natnre  (dnring  the  stage  of  ex- 
citement),  and,  later,  dne  to  paralysis. 

The  OhstrudlcG  Causes. — They  are  principally  situated  in  the  prostate  or 
the  urethra,  although  vesical  calculi  may  enter  the  neck  of  tlie  bladder  and 
lodge  there.  Displacement  and  fracture  of  the  pelvic  bones,  especially  of  the 
]uibes,  may  also  cause  obstruction. 

Prostatic  causes  of  obstruction  are  acute  prostatitis,  prostatic  hypertrophy, 
tumors,  cysts,  calculi  or  tuberculosis. 

The  urethral  cause  is  usually  a  stricture.  The  retention  may  be  due  to  an 
acute  congestion  of  the  mucous  membrane  or  of  the  submucous  tissue  about  this 
lesion,  or  it  may  be  a  late  symptom  dependent  upon  the  great  obstruction  offered 
by  the  stricture  itself.  In  either  case,  it  is  apt  to  be  preceded  by  a  his- 
tory of  fatigue,  cold  or  alcoholic  excesses.  Spasm  of  the  urethra  aids  in 
closing  the  canal.  Foreign  bodies  or  calculi  in  the  urethra  may  also  cause 
retention. 

Atresia  is  another  cause.  This  may  give  rise  to  complete  retention  in  the 
new  born,  if  the  urethra  is  impervious ;  or,  if  it  is  slightly  pervious,  the  trouble 
will  come  on  gradually.     This  latter  condition  is  really  a  congenital  stricture. 

Wounds  of  the  urethra  also  give  rise  to  retention,  either  by  causing  a  con- 
gestion or  an  exudate  which  narrows  its  caliber,  or  by  pressing  upon  its  walls 
on  the  outside  and  thus  rendering  it  impervious. 

Extravasation  of  urine,  due  to  rupture  of  the  urethra  from  an  injury  or 
wound,  or  to  rupture  of  a  urethral  follicle,  may  allow  of  sufficient  leakage  of 
urine  into  the  surrounding  tissues,  either  in  the  pendulous  portion  of  the  iiretlira 
or  the  perineum,  to  block  completely  the  canal  by  its  pressure. 

Abscesses  or  cellulitis  starting  in  the  urethra  or  surrounding  tissue  may  also 
exert  enough  pressure  upon  the  urethra  to  shut  it  off. 

Symptoms. — The  symptoms  of  retention  vary  in  a  marked  degree.  In 
an  acute  attack  of  retention,  such  as  occurs  after  an  operation  or  during  a  fever, 
the  patient  complains  of  pain  steadily  increasing  in  the  suprapubic  region,  and 
of  a  sense  of  fullness  and  inability  to  micturate,  associated  with  a  constant  de- 
sire. On  palpation  over  the  pubes,  there  is  a  feeling  of  tenderness  and  disten- 
tion, and  perhaps  a  globular  tumor  can  be  seen  (Fig.  221),  extending  up  toward 
the  thorax.  Eectal  examination  may  reveal  a  tumor  filling  the  pelvis  like  a 
gravid  uterus. 

Chronic  complete  retention  rarely  occurs,  as  an  overflow  incontinence  usu- 
ally renders  it  incomplete.  It  may  be  observed,  however,  in  certain  cases  of 
paralysis  or  obstruction.  In  complete  retention,  such  as  occurs  in  some  cases 
of  paralysis,  tlie  jiatient  nmy  not  have  been  able  to  void  a  drop  of  urine  for 


258 


SPECIAL   URINAEY    SY:MPT0MS 


months.  There  is,  however,  when  the  hladder  is  full,  a  sensation,  or,  in  cases 
of  paralysis,  where  sensation  is  not  perfect,  a  knowledge  of  how  long  it  takes 
the  bladder  to  fill,  so  that  the  individual  knows  when  the  time  has  arrived  to 
have  recourse  to  the  catheter. 

In  chronic  incomplete  retention,  the  symptoms  are  different,  as  all  eases 
have  residual  urine,  and  the  condition  often  develops  so  slowly  that  the  pa- 


FiG.  221. — The  Outline  of  the  Abdomen  in  a  Case  of  Retention. 

tients  do  not  know  that  they  cannot  empty  their  bladders  until  they  have  been 
so  informed  by  the  physician  after  an  examination.  A  patient  with  a  weak 
bladder  may  carry  for  many  years  about  a  pint  or  more  of  clear  urine  as  a 
residual  deposit,  w^hich  its  weakened  walls  cannot  throw  off.  An  excess  of  the 
fixed  residuum  produces  a  desire  to  urinate,  and  the  patient,  mainly  by  volun- 
tary contraction  of  the  abdominal  muscles,  is  able  to  void  this  excess. 

In  chronic  incomplete  retention,  acute  attacks  of  complete  retention  occur 
principally  when  there  is  obstruction  to  the  escape  of  urine  in  the  form  of 
stricture  or  enlarged  prostate. 

A  patient  with  prostatic  hypertrophy  suffers  from  chronic  incomplete  re- 
tention, in  addition  to  which  his  bladder  is  usually  atonic  and  chronically 
inflamed.  The  usual  symptoms  are  those  of  congestion,  pain,  frequency  of  mic- 
turition, in  addition  to  which  the  urine  is  thick  and  foul-smelling  if  cystitis  has 
developed.  After  overeating  or  drinking,  or  exposure  to  wet  or  cold,  these 
patients  suddenly  find  that  they  cannot  pass  urine.  As  the  bladder  dilates,  they 
have  a  feeling  of  pain  and  a  sense  of  retention,  which  is  usually  relieved  by 
the  methods  wdiich  we  shall  mention  under  Treatment. 

Cases  of  acute  attacks  of  retention  due  to  stricture  are  also  common.  Here 
also  there  is  usually  a  certain  aiuount  of  residual  urine  in  the  bladder.  In  bad 
cases,  the  urethra  behind  the  stricture  is  dilated,  at  times  even  as  far  back  as 
the  neck  of  the  bladder,  which  itself  becomes  dilated  and  no  longer  acts  as  a 
sphincter,  giving  rise  to  an  overflow  incontinence.  In  such  cases,  it  is  often 
difficult  to  expel  any  of  the  remainder  of  the  urine.  Great  straining  and  pro- 
lapse of  the  rectum  may  accompany  the  efforts. 

In  chronic  incomplete  retention,  where  the  bladder  cannot  emj)ty  itself,  cys- 


DISTURBANCES    OF   MICTURITION  259 

titis  iisiiallj  develops,  after  which  sufficient  bacteria  remain  in  the  residuum  to 
contaminate  the  fresh  urine  flowing'  into  it. 

Diagnosis. — When  one  is  caRed  to  see  a  case  of  suspected  retention  of  urine, 
it  is  necessary  to  ascertain  first  if  it  is  really  retention,  and  then  inquire  care- 
fully into  the  history  of  the  case :  whether  it  is  complete  or  incomplete ;  and  if 
complete,  whether  it  is  an  acute  attack  or  not;  and  if  an  acute  attack,  whether 
the  ])atient  has  had  others  of  a  simihir  nature.  It  is  then  important  to  know 
if  there  is  any  other  symptom,  g'eneral  or  local,  which  may  give  us  some  clew 
as  to  the  cause  of  retention;  also  to  ascertain  age  and  family  history. 

To  be  sure  of  an  attack  of  retention,  there  are  certain  other  conditions  that 
must  be  excluded,  as  anuria,  rupture  of  the  bladder  and  extravasation  of  urine. 

It  is  strange  how  generally  anuria  and  retention  are  confounded  with  one 
another.  Anuria  is  a  condition  where  either  the  function  of  the  kidney  has 
ceased  or  the  urine  is  prevented  from  entering  the  bladder,  whereas,  in  reten- 
tion, the  bladder  contains  urine,  but  cannot  empty  itself.  If  no  urine  can  be 
passed  by  the  urethra,  and  it  is  a  question  between  anuria  and  retention,  a  bi- 
manual examination  per  rectum  and  suprapubically  will  usually  disclose  the 
presence  of  a  large  fluid  tumor  if  it  is  retention,  and  a  catheter  inserted  into 
the  bladder  will  draw  off  a  quantity  of  urine  in  vesical  retention  and  none 
in  the  case  of  anuria. 

Rupture  of  the  bladder  can  be  distinguished  from  retention,  as  in  the  former 
case  there  is  no  well-defined  globular  tumor  present,  and  a  catheter  passed  by 
the  urethra  will  bring  away  only  a  slight  amount  of  urine  and  blood.  The 
patient  will  complain  of  great  pain  and  tenderness  in  the  suprapubic  region 
and  perhaps  of  strangury.  If  the  rupture  extends  into  the  peritoneal  cavity, 
general  abdominal  pain,  an  elevation  of  temperature,  and  rajjid  pulse  will  soon 
follow. 

In  extravasation  of  urine,  vesical  retention  may  also  be  present  on  account 
of  the  pressure  of  the  exuded  urine  on  the  urethra  and  it  may  be  impossible  to 
pass  an  instrument  into  the  bladder  on  this  very  account.  The  extravasation 
can  be  seen  as  a  swelling  in  the  perineum,  external  genitals,  or  even  extending 
to  the  abdominal  wall. 

The  history  of  a  case  of  retention  will  reveal  a  great  deal,  as  will  a  survey 
of  the  symptoms.  For  instance,  if  there  is  history  of  an  operation  on  tlie  geni- 
tals or  about  the  rectum,  an  acute  attack  of  retention  can  be  ascribed  to  that 
source.  If  the  patient  has  had  a  stroke  of  apoplexy,  a  fracture  of  the  skull,  or 
is  suffering  from  a  disease  of  the  cord,  or  other  evidences  of  paralysis,  we  can 
assume  that  the  retention  is  due  to  one  of  these  causes.  To  show  that  injury 
to  the  cord  is  followed  by  bladder  dilatation,  I  will  quote  an  experiment  of 
Budge,  who  found  that  division  of  the  cord  in  the  lower  dorsal  region  was  fol- 
lowed by  increased  reflex  action  of  the  sphincter  and  a  greater  degree  of  dis- 
tention of  the  bladder  than  could  be  produced  after  death. 


260  SPECIAL   URINARY   SYMPTOMS 

It  is  rarely  tliat  retention  is  so  complete  tliat  not  a  drop  of  nrine  can  he 
passed,  bnt  we  do  at  times  observe  cases  in  comi)lete  and  partial  paraplegia 
in  which  not  a  drop  can  he  voided  without  the  catheter. 

Having  excluded  paralysis  as  a  cause  of  retention,  we  should  then  look  for 
some  local  trouble  to  account  for  it.  If  the  patient  is  a  man  over  fifty-five  years  of 
age,  with  a  history  of  trouble  in  urinating,  the  stream  coming  tardily,  and  if  ho 
has  sufi^ered  from  such  frequency  of  urination  as  to  be  obliged  to  get  up  often 
at  night,  and  if,  on  certain  occasions,  he  was  imable  to  pass  his  urine  except 
when  aided  by  a  hot  bath  or  by  hot  local  applications,  we  can  assume  that  he 
has  some  prostatic  trouble,  and  can  examine  him  per  rectum  and  per  urethra 
to  see  if  obstruction  is  present  there.  If  an  enlargement  is  found,  it  is  prob- 
ably occasioned  by  senile  prostatic  hypertrophy.  Of  course,  there  are  other 
prostatic  troubles  that  may  give  rise  to  enlargement,  as  acute  prostatitis,  malig- 
nant tumor,  tuberculosis  and  cystic  conditions,  but  these  are  rare.  If  the  patient 
is  a  man  between  twenty-five  and  fifty  years  of  age,  has  had  several  attacks  of 
urethritis,  and  has  recently  urinated  with  increased  frequency  and  wdth  some 
difficulty  and  pain,  his  urethra  should  be  explored  for  stricture,  and  if  one  of 
small  caliber  is  found,  it  is  probably  the  cause  of  his  retention. 

Treatment, — The  treatment  in  retention  of  urine  varies  and  depends  upon 
the  cause,  form  and  degree  of  the  trouble,  and  may  be  divided  into  temporary, 
palliative  and  radical  methods.  It  is  my  intention  to  consider  the  different 
forms  from  the  standpoint  of  degree  and  cause. 

Acute  Attacks  of  Complete  Retention. — In  acute  attacks  of  complete 
retention,  such  as  occur  after  operations  in  toxic,  comatose  conditions,  or  fevers, 
the  surgeon  should  insert  a  soft-rubber  catheter  into  the  bladder  and  draw  off 
one  pint  of  the  urine.  If  then  hot  applications  are  made  over  the  pubes,  the 
patient  will  probably  be  able  to  pass  urine,  after  an  hour,  without  difficulty.  If 
not,  the  catheter  should  again  be  introduced  at  the  end  of  two  hours,  and  again 
every  three  hours,  until  spontaneous  urination  has  been  reestablished,  drawing 
off  each  time  only  a  pint  of  urine.  This  will  usually  take  place  after  a  few 
catheterizations,  although  sometimes  it  requires  a  longer  period. 

Acute  Attacks  of  Complete  Retention  Occurring  in  Cases  of 
Chronic  Incomplete  Retention. — Attacks  of  this  nature,  occurring  in 
people  who  have  a  certain  amount  of  residual  urine  habitually,  are  those  most 
commonly  encountered.  They  usually  occur  in  men  suffering  from  stricture 
or  enlarged  prostate  and  are  generally  caused  by  exposure  to  cold  or  wet,  dissi- 
pation, or  by  excesses  in  eating  or  drinking.  Here  the  patient  suddenly  finds 
that  he  cannot  urinate,  although  he  has  been  able  to  pass  a  fair  amount  at  fre- 
quent intervals,  for  some  time. 

This  is  a  critical  moment  for  him,  as  it  is  often  here  that  his  future  woes 
begin.  A  case  in  this  condition  should  be  handled  with  the  greatest  care,  as 
the  bladder  and,  perhaps,  the  ureters  and  jDelves  of  the  kidneys  are  more  or  less 


DISTURBANCES    OF   MICTURITION 


261 


distended  or  congested  and  in  a  favorable  condition  to  Lc  infected.  The  cathe- 
terization should,  therefore,  l)e  made  under  the  strictest  asepsis  or  antisepsis, 
and  care  must  be  taken  to  avoid  lacerating,  wounding  or  bruising.  (See  chapter 
on  Asepsis  and  Antisepsis.) 

The  treatment  of  these  attacks,  or  exacerbations  of  chronic  ones,  is  the  same 
as  that  of  an  acute  attack  independent  of  a  chronic  condition ;  namely,  to  pass 
a  catheter  and  draw  off  a  pint  of  urine,  another  pint  in  two  hours,  and  then  a 
pint  every  three  hours  until  the  patient  can  urinate  spontaneously,  as  has  just 
been  mentioned.  Frequently,  however,  a  catheter  will  not  enter,  in  which  case 
the  patient  should  have  a  hot  sitz  bath,  which  may  enable  him  to  pass  a  small 
amount  of  urine  while  seated  in  the  water.  If,  however,  he  is  unable  to  pass 
any  urine  in  this  way,  he  should  then  have  a  hypodermic  injection  of  a  quarter 
of  a  grain  of  morphin,  hot  applications  over  the  pubes  and  perineum,  and  should 
lie  down  for  about  an  hour,  when  another  attempt  should  be  made  to  catheterize 

him,  at  first  with  a  small  soft-rubber  cathe- 
ter, and,  if  unsuccessful  with  such  an  in- 
strument, then  with  a  woven  one  with  an 
olivary  tip.  If  the  patient  is  an  old  man, 
an  elbowed  woven  catheter  should  be  used. 
In  case  these  measures  do  not  meet  with 
success,  he  should  be  given  another  hot  sitz 
bath  and  another  attempt  at  catheterization 
should  be  made. 


Fig.  222.— The  Blasucci  Catheter. 
Contains  a  mandrin  with  a  pliable  filiform  guide  at  its  end,  seen  in  the  bladder. 


262  SPECIAL   URINARY    SYMPTOMS 

Sometimes,    when    other    catheters    fail,    the    Blasiicei    instrument    can    be 
passed  (Figs.  222,  223  and  224).     If  this  attempt  fails  and  he  cannot  i)ass 


Fig.  223. — The  Blasucci  Catheter. 
The  mandrin  and  filiform  are  being  -nathdrawn  from  the  catheter. 

nrine,    he    should    be    aspirated    suprapubically    and    a    pint    of    urine    with- 
drawn, after  which  he  should  be  aspirated  every  four  hours  until  he  is  able 


Fig.  224. — The  Blasucci  Catheter. 
The  mandrin  has  been  withdrawn  and  the  urine    is  seen  flowing  into  a  basin. 


DISTURBANCES    OF   MICTURITION  263 

to  urinate  spontaneously,  or  a  catheter  can  be  passed.  In  case  such  a  re- 
sult is  not  obtained,  an  operation  should  be  performed,  preferably  a  perineal 
section.  It  is  very  rarely,  however,  that  an  immediate  operative  procedure  has 
to  be  resorted  to,  as  these  patients  are  almost  always  able  to  pass  sufficient  urine 
to  be  relieved  if  a  catheter  cannot  be  inserted.  In  case  it  is  difficult  to  pass  the 
catheter  at  any  time,  when  one  finally  enters,  it  is  prudent  to  tie  it  in  for  twenty- 
four  hours  and  insert  a  plug,  which  can  be  withdrawn  every  two  or  three  hours, 
until  the  bladder  is  empty.  In  twenty  years  of  the  most  active  practice  in 
bladder  surgery,  I  cannot  recall  having  had  to  aspirate  more  than  three 
patients. 

The  best  lubricant  is  glycerin ;  next  to  this,  Casper's  prescription : 

I^   Hydrarg.  oxycyanat gr.  iijss ; 

Glycerini f ovss ; 

Tragacanth   gr.  xlvj ; 

Aquse  dist.  sterilizat f^iij- 

The  mixture  is  put  up  in  tubes. 

In  case  a  catheter  does  not  easily  pass  with  such  lubricants,  half  an  ounce 
of  sterile  olive  oil,  which  is  more  than  the  anterior  urethra  will  readily  hold, 
should  be  injected  and  held  in  for  several  minutes  in  the  hope  that  some  of  it 
will  pass  through  the  stricture  and  lubricate  its  walls.  Before  allowing  any 
oil  to  escape  from  the  meatus,  while  the  urethra  is  still  somewhat  dilated,  an 
attempt  should  be  made  to  pass  a  catheter  or  filiforms. 

If  a  catheter  can  be  introduced  into  the  bladder,  it  may  be  allowed  to  re- 
main as  a  retained  catheter.  It  should  be  plugged,  and  every  two  hours,  until 
the  bladder  is  empty,  twelve  ounces  of  urine  should  be  withdrawn. 

In  case  neither  a  soft-rubber  nor  woven  catheter  can  be  introduced,  an  en- 
deavor should  be  made  to  pass  a  filiform.  If  successful  and  some  urine  escapes 
by  its  side,  it  may  be  left  in  place,  in  the  hope  that  the  urine  will  drain  off  by 
its  side ;  or  a  metal  tunneled  catheter  may  be  forced  over  it  into  the  bladder, 
thus  allowing  as  much  urine  to  be  drawn  off  as  Ave  desire. 

I  do  not  advocate  this  latter  procedure,  however,  unless  it  is  considered 
desirable  to  operate  immediately  afterwards. 

If  a  patient  cannot  pass  urine  and  an  instrumcut  cannot  be  introduced  that 
will  allow  the  escape  of  urine,  then  there  are  but  two  things  to  do.  One  is  to 
perform  paracentesis  (aspiration),  ancl  the  other  a  radical  operation. 

It  is  probable  that  by  keeping  the  patient  in  bed  and  resorting  to  the  palli- 
ative methods  already  referred  to,  he  will  be  able  to  urinate  spontaneously  in 
a  few  hours,  but  only  in  small  quantities ;  or  else  the  congestion  will  go  down 
sufficiently  to  allow  the  catheter  to  be  passed.  Patients  may  be  aspirated  fre- 
quently, each  time  but  a  pint  of  urine  being  withdrawn  ;  I  have  known  a  patient 
to  be  aspirated  over  one  hundred  times  without  any  ill  effects. 


264 


SPECIAL   URINARY   SYMPTOMS 


Paracentesis  should  always  be  performed  by  tlie  suprapubic  route.  The 
point  for  the  introduction  of  the  instrument  should  be  in  the  median  line,  just 
above  the  symphysis.  The  trocar  should  be  pushed  inward  and  downward  for 
about  two  inches,  the  stilet  should  then  be  taken  out  and  a  certain  amount  of 
urine  withdrawn  (Fig.  225).'  A  piece  of  plaster  should  be  placed  over  the 
puncture  and  the  patient  put  to  bed. 


Fig.  225. — Paracentesis.  The  grooved  cannula  or  an  aspirating  needle  is  thrust  through  the  ab- 
dominal and  bladder  walls,  just  above  the  pubes  toward  the  tip  of  the  forefinger,  which  is  in  the 
rectum  just  above  the  prostatic  base  and  acts  as  a  guide. 

The  complete  emptying  of  the  bladder  at  once  may  produce  a  distention  of 
the  blood  vessels  of  the  urinary  tract  and  a  consequent  engorgement  of  its  sur- 
face. Within  a  few  hours,  the  urine  may  contain  a  little  blood  (hematuria),  in- 
dependent of  mechanical  injury.  If  the  urinary  tract  was  infected  before  or 
during  the  catheterization,  the  temperature  may  rise,  the  tongue  become  dry  and 


DISTURBANCES   OF   MICTURITION  265 

brown,  and  the  patient  may  develop  a  condition  known  as  nrinary  fever.  If  the 
]iatient's  kidneys  are  damaged,  even  if  no  infection  is  present,  the  kidneys  may 
l)ecome  congested,  resnlting  in  nremia  and  death.  The  renal  congestion  may 
even  give  rise  to  death  in  a  few  lionrs  from  suppression. 

The  conservative  method  recommended  of  gradually  evacuating  the  bladder 
may  be  used  with  advantage  in  cases  of  retention.  It  consists,  first,  in  evacuat- 
ing about  one  pint  of  urine  by  catheter,  which  should  be  plugged  and  retained. 
At  intervals  of  two  hours,  until  the  bladder  is  empty,  the  plug  should  be  with- 
drawn and  twelve  ounces  of  urine  allowed  to  escape. 

CirRo:xic  Complete  RETENTioisr  Due  to  Paralysis. — In  chronic  complete 
retention  due  to  paralysis,  such  as  occurs  in  cases  of  transverse  myelitis,  the 
patient  should  be  catheterized  every  six  hours. 

CHROisric  Complete  Retention  Due  to  Obstruction. — In  chronic  com- 
plete retention  due  to  obstruction,  the  treatment  should  be  the  same  as  in  chronic 
eases  due  to  paralysis,  if  this  is  possible.  These  cases  are,  however,  almost  al- 
ways due  to  hypertrophy  of  the  prostate  or  to  stricture,  so  that,  in  the  former 
condition,  w^e  should  be  obliged  to  use  an  elbowed  soft-rubber  or  woven  catheter. 
In  such  cases,  pain,  irritation  and  tenesmus  are  often  so  great  that  the  catheter 
may  have  to  be  passed  more  frequently  in  order  to  give  the  patient  relief.  In- 
ternal urinary  antiseptics,  bladder  irrigations  of  antiseptic  solutions  by  means 
of  the  catheter,  and  antispasmodics  by  the  mouth  or  rectum,  should  be  given. 

Chronic  Incomplete  Retention  Due  to  Paralysis. — In  chronic  incom- 
plete retention  due  to  paralysis,  the  bladder  w^all  is  partially  paralyzed,  residual 
urine  is  present,  and  cystitis  is  apt  to  occur.  Here  the  frequency  of  catheteriza- 
tion should  depend  on  the  amount  of  residual  urine  present;  if  four  ounces, 
once  a  day;  four  to  eight  ounces,  twdce  a  day;  eight  to  twelve  ounces,  three 
times  a  day ;  over  twelve  ounces,  four  times  a  day. 

If,  in  addition  to  this,  cystitis  is  present,  we  should  wash  out  the  bladder 
every  day  or  two  through  the  catheter  with  some  antiseptic  solution,  as  one  of 
boric  acid  or  silver  nitrate,  and  give  internally  a  urinary  antiseptic. 

In  all  cases  of  chronic  incomplete  retention,  the  treatment  of  the  inftamed 
and  atonic  ivall  of  the  Ijladder  is  to  be  considered.  A  patient  may  live  for  years 
with  a  chronic  cystitis,  if  his  bladder  is  treated  properly.  This  trouble  is  gen- 
erally not  curable,  but  few  inflammatory  conditions  yield  to  treatment  with 
more  gratifying  results  to  both  the  physician  and  the  patient. 

The  methods  of  toning  up  an  atonic  bladder  are:  By  using  remedies  which 
will  excite  contraction  of  the  bladder  wall,  such  as  strychnin,  cold  sponging, 
or  douching  over  the  pubes,  and  counterirritation  to  the  spine. 

Civiale  recommended  cold-water  injection  into  the  bladder,  beginning  with 
tepid  w-ater  and  gradually  decreasing  the  temperature  to  60°  F.  This  should 
be  done  after  emptying  the  bladder.  Two  or  three  of  these  injections  may  be 
given  one  after  another.     These  generally  excite  contractions,  which,  once  hav- 


266 


SPECIAL    UrvlNAKY    SYMPTOMS 


ing  begun,  will  bring  about  favorable  results.  The  daily  injections  for  a  fort- 
night will  usually  cause  marked  improvement. 

The  faradic  current  given  by  placing  one  pole  over  the  lumbar  or  hypogas- 
tric region,  and  introducing  the  other  into  the  bladder  in  the  form  of  a  hard- 
rubber  sound,  with  a  metallic  tip,  is  often  of  great  service.  This  should  be 
moved  around  until  it  comes  in  contact  with  the  different  parts  of  the  bladder 
wall  for  five  minutes  at  a  sitting.  Various  preparations,  such  as  those  of  iron, 
strychnin  and  other  tonics,  are  recommended. 

Chronic  Incomplete  Retention  Due  to  Obstruction. — In  chronic  in- 
complete retention  due  to  obstruction,  we  have  a  very  common  condition,  such 
as  is  usually  seen  in  cases  of  enlarged  prostate  or  tight  stricture.  The  treat- 
ment of  the  bladder  in  these  cases  should  depend  very  much  on  the  amount  of 
residual  urine.  The  bladder  should  be  catheterized  as  often  as  indicated  and 
irrigated  with  an  antiseptic  solution.  A  urethral  stricture,  if  present,  should  be 
dilated. 

Radical  Treatment. — The  causes  of  complete  or  incomplete  retention, 
when  obstruction  is  due  to  mechanical  interference,  should  be  treated  by  opera- 
tion, as  recommended  in  the  respective  chapters  on  these  subjects :  urethrotomy 
for  urethral  stricture  and  prostatectomy  for  prostatic  hypertrophy. 

The  classification  of  retention  of  urine  is  as  follows : 


(1)   According   to   the   degree   of 
retention 


(3)   Cause 


(2)    Degree  of  intensity  and  dura- 
tion 


Comj^lete — when  no  urine  can  be  passed. 
Incomplete — when  not  all  the  urine  can  be 
passed. 


Acute 


Chronic 


Obstructive. 

Traumatic. 

Paralytic. 


When  the  patient  suddenly 
finds  it  impossible  to  urinate. 

An  acute  attack  taking  place 
during  chronic  incomplete 
retention,  is  really  an  acute 
exacerbation. 

When  the  patient  habitually, 
for  a  considerable  time,  has 
not  been  able  to  empty  his 
bladder. 


In  the  following  table  I  classify  them  according  to  acute  and  chronic,  speak- 
ing first  of  the  purely  acute ;  then  those  purely  chronic,  which  will  be  divided 
into  complete  and  incomplete. 


DISTURBANCES    OF    MICTURITION 


267 


Acute   attacks  of  complete   reten- 
tion may  be  due  to 


Chronic    retention     (complete    or 
incomplete) 


Acute  parenchymatous  prostatitis. 

Follicular  prostatitis. 

Stricture  or  prostatic  hypertrophy. 

Alcoholism. 

Temporary  stupor. 

Voluntary  refraining  from  urinating. 

Fever,  as  typhoid. 

Pregnancy. 

Urethral  calculus. 

Extravasation  of  urine. 

Periurethral  abscess  or  cellulitis. 

Fracture  of  the  pelvis. 

'  Paraplegia  ^  ^  .. 

T-T-      .   n     .     ^Jcrom  disease  or  miury. 
Hemiplegia  J 

Tabes  and  lateral  sclerosis. 

Pott's   disease. 

Prostatic  hypertrophy. 

Prostatic  tumors  or  cysts. 

Urethral  stricture. 

Atresia  in  the  newborn. 


In  chronic  cases  of  partial  retention  (that  is,  when  there  is  residual  urine 
present),  the  patient  may  suddenly  find  that  he  cannot  urinate,  thus  making  an 
acute  attack  of  retention.  In  paralytic  and  chronic  obstructive  cases,  there  may 
be  an  overflow  retention  or  incontinence. 

Incontinence  of  Urine 

Definition. — True  incontinence  is  the  involuntary  discharge  of  urine  through 
the  urethra.  False  incontinence  is  a  condition  in  which  an  irresistible  desire 
to  urinate  occurs,  causing  the  patient  to  void  every  few  minutes,  or  giving  rise 
to  precipitate  urination. 

Varieties  and  Causes. — The  following  table  shows  the  varieties  of  true  in- 
continence and  their  causes: 


I.  Retention  with  Incontinence  or  Overfeow  Incontinence. 


(1)  Due  to  an  obstruction  in  the 
vesico-urethral  path 


f       (a)    Strictures  of  the  urethra,   trau- 
matic or  acquired. 
(J))    Chronic  enlarged  prostate. 
(c)    Foreign    bodies,    stones,    tumors 
blocking    the    path;    outside 
pressure ;  or  cystocele. 


268 


SPECIAL   URINAKY    SYMPTOMS 


(2)   Due  to  a  change  in  the  nerr 
oiis  mechanism  of  the  blad-  ^ 
der 


(3)   Due   to   a   loss   of  muscular 
tone  of  the  bladder 


(a)  Locomotor  ataxia  ;  myelitis  ;  pa- 
ralysis.   (Bladder  paralyzed.) 

(h)  Comatose  conditions;  apoplexy; 
cerebral  concussion ;  narcotic 
poisoning.  (Consciousness  of 
desire  abolished.) 

Senile  atrophy  of  the  bladder. 


II.  Without  Retention. — Due  to  insufficiency  of,  or  interference  with, 
the  sphincter  mechanism  from  the  following  causes : 

(a)   Enuresis  nocturna  in  children. 


(1)    Idiopathic  or  functional 


(2)   Mechanical 


(&)   i^ervous     and     physical     incon- 
tinence   in    adults ;    hysteria ; 
neurasthenia. 
Stone  or  foreigTi  body  or  tumor  in 
the    neck    of    the    bladder,    partly 
holding  the  sphincter  open. 

(3)    Tuberculosis  of  the  neck  of  the  bladder,  giving  rise  to  loss  of  tissue 
from  ulcerations  that  prevent  its  uniform  closing.^ 

For  prostatic 

abscess. 

For  stricture. 

For    perineal 

p  r  o  s  t  a  - 

tectomy. 


(4)   Traumatic,"  after 


(a)   Perineal  section 


(5)   Atonic,  affecting  the  sphinc- 
ter only 


I 


(h)    Bottini  operation. 

(c)  Forcible  dilatation  of  sphincter, 

(d)  Fracture  of  the  pelvis  affecting 

sphincter. 

(a)  Aiter  childbed,  with  subinvolu- 

tion of  the  uterus. 

(b)  In  old  women,  with  atrophy  of 

the  genito-urinary  organs. 


1  This  condition  described  by  many  authorities  is  probably  rare,  as  the  author  has  never 
seen  a  case  of  true  incontinence  in  vesical  tuberculosis  that  he  could  prove  to  be  such  either  by 
clinical  methods  or  post-mortem  findings.  Many  cases  of  false  incontinence  in  vesical  tuber- 
culosis resemble  true  incontinence  so  closely  as  to  be  mistaken  for  it. 

^  Childbirth,  with  tearing  of  the  vesical  sphincter  usually  given  as  a  cause  of  incontinence, 
has  been  omitted  from  this  table,  as  in  fifty-five  thousand  (55,000)  cases  in  one  of  the  largest  ly- 
ing-in hospitals  in  the  world,  no  such  case  has  been  recorded.  Its  presence  on  the  list  together 
with  the  usual  causes  might  mislead  the  practitioner  for  whose  use  this  table  has  been  prepared. 


DISTURBANCES    OF   MICTURITION  269 

Clinical  Features. — The  clinical  types  which  can  be  distinguished  are  as 
follows : 

(1)  Dribbling. 

(2)  Sudden  discharge  of  entire  contents  of  the  bladder  at  intervals,  giving 
bladder  time  to  fill  up. 

(3)  Discharge  of  the  contents  of  bladder  by  steady  pressure  over  it. 

(1)  Dribbling. — This  is  characteristic  of  overflow  retention  in  true  in- 
continence. In  most  cases  the  accumulation  of  urine  gradually  overcomes  the 
resistance  of  the  sphincter  and  the  urine  begins  to  dribble  out. 

As  the  bladder  keeps  filling  up,  there  being  usually  polyuria  in  these  cases, 
the  dribbling  continues,  with  interruptions.  Usually  the  overflow  dribbling  of 
retention  appears  at  night,  but  later  continues  through  the  tM^enty-four  hours. 
Dribbling  may  occur  without  retention  in  those  cases  of  incontinence  in  which 
the  sphincter  is  interfered  with.  (See  Table  II,  2,  4.)  Sometimes  in  these 
cases  the  discharge  of  small  amounts  of  urine  may  be  brought  about  by  sudden 
jars,  such  as  occur  in  coughing,  sneezing,  etc.,  while  the  bladder  may  retain 
its  contents  during  sleep.  Slight  dribbling  is  also  due  to  a  few  drops  of  urine 
collecting  in  dilations  behind  strictures,  in  cases  in  which  the  bladder  sphinc- 
ter holds. 

(2)  Sudden  Discharge  of  the  Entiee  Contents  of  the  Bladder  at 
Intervals,  Giving  the  Bladder  Time  to  Fill  up  Again. — The  involuntary 
discharge  of  large  amounts  of  urine  in  a  steady  stream,  from  time  to  time,  while 
the  fluid  is  retained  in  the  intervals,  is  characteristic  of  enuresis  nocturna  in 
children ;  of  cerebral  conditions  accompanied  by  coma ;  of  narcotic  poisoning, 
concussion,  epilepsy,  etc.,  in  which  cases  the  patient  does  not  feel  any  desire 
to  urinate,  though  the  bladder  be  full. 

(3)  Discharge  of  Urine  by  Steady  Pressure  on  the  Bladder. — This 
is  a  symptom  indicating  the  reverse  of  the  above,  namely,  a  lowered  reflex  sus- 
ceptibility of  the  organ,  and  occurs  when  the  reflexes  are  generally  lowered  in 
locomotor  ataxia,  myelitis,  etc.  This  form  of  incontinence  is  characterized  by 
the  fact  that  the  contents  of  the  bladder  can  be  readily  expressed  when  pressure 
is  made  upon  the  suprapubic  region.  The  pressure  on  the  bladder,  however, 
that  usually  causes  such  incontinence,  is  a  fibroid  or  subinvoluted  uterus,  an 
abdominal  or  pelvic  tumor,  or,  in  some  cases,  the  weight  of  the  intestines  in 
ptosis,  or  of  the  omentum  when  standing. 

Diagnosis. — True  incontinence  is  distinguished  from  false  by  the  subjective 
presence  in  the  latter  of  the  desire  to  urinate.  We  must  be  sure,  of  course,  to 
exclude  cases  of  willful  discharge  of  urine  in  bed,  etc.,  for  the  purpose  of  nuilin- 
gering. 

If  an  examination,  general  and  local,  fails  to  reveal  the  causes  of  true  incon- 
tinence, we  can  assume  that  the  case  is  one  of  false  incontinence. 

Among  the  causes  of  false  incontinence  are  the  followino-:  Acute  inflannua- 


270 


SPECIAL   URINARY   SYMPTOMS 


tion  of  the  posterior  urethra  in  verv  nervous  iii(livi(hials;  any  of  the  causes  of 
true  incontinence  which  have  not  reached  ihc  jioint  where  they  are  beyond  the 
control  of  the  will ;  acute  prostatic  trouhles ;  and  tuberculosis  of  the  bladder. 
The  last-mentioned  is  the  most  common  and  typical  of  all  causes  and  should 
always  be  suspected. 

Treatment  of  Incontinence. — Strictures,  where  there  is  bnt  slight  dribbling 
after  urinating',  due  to  dilatations  behind  them,  are  nsually  situated  anteriorly, 

and  dilatation  or  internal  urethrotomy  should  be 
resorted  to.  In  cases  in  which  there  is  overflow 
incontinence,  the  stricture  is  usually  deep-seated 
and  of  long  standing,  and  would  reqnire  an  exter- 
nal urethrotomy.  When  due  to  enlarged  prostate, 
the  gland  should  be  enucleated,  or  a  Bottini  opera- 
tion performed,  or  catheter  life  resorted  to.  For- 
eign bodies  and  stones  holding  the  sphincter  open 
and  occluding  to  a  sufficient  degTee,  to  cause  re- 
tention, should  be  removed.  Tumors  should  also 
be  removed  if  the  growth  has  not  involved  too 
much  tissue. 

In  locomotor  ataxia,  myelitis  and  paralysis, 
the  bladder  should  be  emptied  four  times  in  twen- 
ty-four hours,  and  should  be  washed  with  silver 
solution  and  a  urinal  be  worn  (Fig.  226).  Some- 
times in  cerebral  lesions,  the  condition  improves 
somewhat,  but  in  diseases  of  the  spinal  cord  there 
is  rarely  any  improvement.  Cases  in  which  the 
bladder  is  atonic  should  be  treated  by  uitrate-of- 
silver  irrigations,  by  electricity  to  the  inside  of 
the  bladder,  injections  of  cold  water  and  internally 
by  iron  and  strychnin. 

In  enuresis  nocturna  in  children,  the  child,  if 
a  male,  should  be  circumcised.  He  should  be  ex- 
amined for  a  congenital  urethral  stricture,  which 
should  be  cut  if  present.  He  should  sleep  with  a 
knotted  towel  about  him  and  with  the  knots  behind  his  back.  He  should  be 
awakened  at  a  certain  time  to  empty  his  bladder.  Internally,  he  should  have 
hyoscyamus  and  bromid  before  retiring.  If  five  years  of  age  hyoscyamin,  gr. 
•g^;  bromid,  grs.  v. 

In  cases  of  hysteria  and  neurasthenia,  bromid,  belladonna  and  hyoscyamus 
should  also  be  given. 

Fibroid  tumors  pressing  on  the  bladder  should  be  removed.     A  uterus  press- 
ing upon  it  should  be  fixed  in  place  by  shortening  the  ligaments  or  by  anchoring 


Fig.  226. — The  Method  of  Wear- 
ing A  Urinal.  The  rubber 
urinal  is  strapped  about  the 
hips.  The  external  genitals  fit 
in  the  pouch  below  the  pubes, 
from  which  a  tube  runs  down 
to  a  reservoir  on  the  inner  side 
of  the  leg. 


CHANGES    IN    THE    AMOUNT    OF   URINE  '    271 

it  to  the  abdominal  \vall,  well  u]).  Bad  tears  of  the  bhadder  sphincter  during 
childbirth  should  be  immediately  repaired.  Extensive  cuts  through  the  sphinc- 
ter at  the  time  of  operations  for  stricture  or  prostatic  abscesses,  in  the  Bottini 
prostatotomy,  or  in  perineal  prostatectomy,  may  give  rise  to  an  incontinence, 
for  the  treatment  of  wliich  no  satisfactory  remedy  has  yet  been  devised.  Time, 
electricity,  prostatic  and  vesical  douches,  and  tonic  remedies  may  benefit  them; 
but  many  of  the  bad  cases  are  never  cured. 

Subinvolution  of  the  uterus  after  childbirth  should  be  treated  by  curettage 
and  ventral  suspension. 

In  many  cases  of  incontinence,  the  cause  of  which  cannot  be  discovered  by 
the  history,  examination,  or  urinary  analysis,  the  patients  are  relieved  by  symp- 
tomatic treatment. 

In  women  cystocele  is  a  frequent  cause,  in  which  case  they  are  readily  cured 
by  an  anterior  coljDorrhaphy  and  repairing  the  perineum. 

A  prolapsed  uterus  should  be  suspended,  and  an  anterior  colporrhaphy  or 
perineorrhaphy  performed,  if  indicated. 

There  is  no  other  condition  in  urinary  diseases  so  trying  to  the  patient  as 
urinary  incontinence;  therefore,  every  means  should  be  taken  to  discover  and 
remove  the  cause.  Cystoscopy  should  give  us  a  clear  idea  of  the  condition  -of 
the  bladder.  If  no  cause  is  seen  and  if  no  disease  of  the  nervous  system  is 
discovered,  an  exploratory  laparotomy  should  be  performed  with  the  object  of 
seeing  if  there  is  any  interference  with  the  bladder  function  from  the  outside. 
A  large  gynecological  service  leads  me  to  believe  that,  in  women,  such  inter- 
ference is  due  to  adhesions  of  the  bladder  to  the  neighboring  structures,  and  that 
the  consequent  displacement  and  interfered  function  of  the  bladder  is  more  com- 
mon than  was  formerly  supposed. 

II.    CHANGES   IN   THE   AMOUNT   OF  URINE 

POLYIJKIA 

The  term  polyuria  indicates  an  increased  secretion  of  urine  and  is  a  symp- 
tom, not  a  disease.  There  is,  however,  a  form  of  polyuria  which  seems  to  exist 
independently  of  any  other  condition  and  is  known  as  "  essential  polyuria  "  or 
polyuric  diabetes. 

The  term  polyuria  is  usually  applied  to  cases  in  which  the  amount  of  urine 
exceeds  two  liters  in  twenty-four  hours.  It  must  be  carefully  distinguished 
from  frequency  of  urination,  because,  as  we  have  seen,  the  latter  may  exist 
with  a  normal  amount  of  urine.  The  amount  of  urine  for  twenty-four  hours 
should  be  accurately  measured  before  making  a  diagnosis  of  polyuria.  Malin- 
gering by  the  patient  who  may  add  water  to  his  urine  should  be  excluded. 

Etiology. — Transient  polyuria  may  exist  from  extraneous  causes  in  health, 
and  can  usually  be  made  out  without  difficulty,  as  in  people  who  drink  large 


272  sPE(^rAL  URTXARY  SY:\rPTo:\r?; 

anioniits  of  cold  Avatcr  and  coiisciiiicntlv  have  a  polyuria  of  rciiiai'kalilo  (lo;Lir('o 
within  a  few  hours.  Warm  enemas,  and  warm  Huids  drunk  give  rise  to  a  poly- 
uria. The  same  is  true  of  a  cold  bath,  while  a  hot  bath  diminislies  the  auiouut 
of  urine  secreted.  The  ingestion  of  diuretics  and  other  tliera])eutic  measures 
also  transiently  increases  the  urinary  secretion.  Other  imporiaut  causes  of 
polyuria  are  sudden  emotions,  epileptic  seizures,  nervous  strain,  mcutal  ai)pli- 
cation  occurring  especially  in  those  not  accustomed  to  it,  causing  a  ])olyiiria 
wliic'h  disappears  as  soon  as  the  mental  work  is  discontinued.  This  uuiy  be 
termed  "  nervous  polyuria." 

The  polyuria  of  convalescence  is  another  type  of  the  transient  form.  This 
includes  the  increase  in  the  amount  of  urine  noted  at  the  end  of  many  diseases. 
The  object  of  this  is  to  rid  the  system  of  certain  products  which  are  excreted 
in  large  amount,  as,  for  example,  the  chlorids  in  pneumonia. 

A  convenient  division  of  the  polyurias  occurring  from  organic  diseases  is 
into  the  moderate  polyuria,  reaching  up  to  four  liters,  and  the  marked  polyurias, 
reaching  as  high  as  ten  liters  and  over.  The  moderate  type,  according  to  Merck- 
len,  indicates  disease  of  the  urinary  organs,  while  the  marked  polyurias  are 
seen  in  diabetes  mellitus  and  diabetes  insipidus. 

The  causes  of  polyuria  may  be  thus  tabulated,  after  Castaigne's  description : 

A.    MODERATE    POLYURIAS 

I.  Due  to  Renal  Disease. 

(a)  Chronic  interstitial  nephritis, 

(b)  Amyloid  kidney. 

(c)  Reflex  congestion  of  the  kidney. 

(d)  Pyelonephritis. 

(e)  Tuberculous  kidney, 
II.  Due  to  Heart  Disease. 

Permanent  in  persons  with  cardiosclerosis, 

III.  Due  to  Liver  Disease, 

Cirrhosis   (sometimes). 

IV,  Due  to  Nervous  Causes. 

Hysteria. 
Epilepsy. 
Exophthalmic  goiter. 

Cerebral  hemorrhage. 


Reflex  from 


]\Ieningitis. 
Sclerosis  of  the  cord. 
General  paresis. 
Sciatica. 
Mental  strain. 


CTTANCES    TN    TTTE    AlVfOT^NT    OV    T^RIXE  273 

B.     iMARKED    rOLYlIKIAS 

I.  Glycosuria — diabetes  mellitus. 

II.  Uricacideiiiia — nitrogenous  diabetes. 

III.  Phosphaturia — phospliatic  diabetes. 

IV.  Diabetes  insipidus — hydruria. 

The  urologist  is  especially  interested  in  the  first  group  of  polyurias,  due  to 
renal  disease.  Even  if  interstitial  nephritis  and  amyloid  kidney  have  been 
excluded,  there  may  be  a  polyuria  due  to  trouble  further  down  in  the  urinary 
tract.  The  urethra,  bladder,  prostate  and  ureter  should  be  examined  to  make 
sure  of  their  integrity.  Frequently  strictures,  chronic  cystitis  and  hypertro- 
phied  prostate  are  reflex  causes  of  a  polyuria,  or  else  the  ascending  infection  to 
which  they  give  rise  produces  a  pyelonephritis  and  so  gives  rise  to  a  polyuria. 
(See  Table  A,  I,  a,  b,  c  and  d.)  With  the  latter  there  will  be  purulent  urine 
from  the  pelvis  of  the  kidney  on  ureteral  catheterization,  while  wdth  the  reflex 
form  of  polyuria  in  these  conditions  the  urine  will  be  clear. 

Anuria 

Definition. — The  word  anuria  is  derived  from  an,  without,  and  ouron,  urine. 
It  means,  therefore,  literally  a  total  absence  of  urinary  secretion,  although,  clin- 
ically, we  understand  by  anuria  the  absence  of  urine  from  the  bladder,  which 
is  ascertained  by  the  introduction  of  a  catheter  into  this  organ  after  the  patient 
has  failed  to  urinate  for  some  time. 

Etiology. — Anuria  may  be  due  either  to  an  arrest  of  secretion  of  urine 
(nonobstructive  anuria)  or  to  an  obstruction  in  the  ureters  (obstructive 
anuria). 

A.  NoNOBSTRiJCTivE  Anuria — A  SUPPRESSION  OF  Urine. — A  ccssatioii  of 
the  secretion  of  urine  may  be  induced  (1)  by  disease  of  the  secretory  apparatus 
of  the  kidney,  (2)  by  circulatory  disturbances  affecting  the  renal  circulation, 
(3)  by  certain  nervous  affections,  or  (4)  by  toxic  agents. 

(1)  Anuria  due  to  lesions  of  the  kidney  may  occur  in  either  acute  or  chronic 
nephritis.  In  acute  nephritis  due  to  scarlet  fever  or  other  causes,  there  may 
be  suppression  of  urine  due  to  a  degeneration  of  the  epithelium  of  the  tubules, 
with  or  without  involvement  of  the  glomeruli.  In  chronic  nephritis  the  kidney 
may  become  so  atrophied  and  sclerosed  that  it  no  longer  contains  sufficient  secre- 
tory elements  to  maintain  the  process  of  excretion.  The  anuria  of  chronic 
nephritis,  however,  is  more  frequently  the  result  of  a  complicating  passive  con- 
gestion, or  an  edema  of  the  interstitial  tissue  which  so  compresses  the  urinary 
tubules  that  secretion  is  arrested. 

(2)  Anuria  due  to  circulatory  disturbances  is  produced  by  a  venous  stasis 
in  diseases  of  the  heart,  or  else  by  large  double  infarcts  of  the  kidney.     In  the 


274  SPECIAL   URIXARY   SYMPTOMS 

former  type,  the  chief  factor  is  the  dilatation  of  the  right  ventricle,  which  pro- 
duces venous  stasis  of  the  kidney.  There  is  always  a  disease  in  the  kidney  in 
such  cases,  and  the  venous  stasis  suffices  to  produce  edema  of  the  interstitial 
tissue  and  thus  to  choke  the  tubules.  Cases  of  double  plugging  of  the  ureters 
by  desquamation,  as  in  scarlet  fever,  or  by  suppuration  products,  in  cases  like 
nephritis,  or  of  other  origin  are  reported.  Such  cases  must,  however,  be  very 
rare,  the  lesion  existing  by  far  more  commonly  as  unilateral. 

(3)  Anuria  due  to  nervous  causes  may  depend  on  a  variety  of  conditions. 
Complete  suppression  of  urine  has  been  noted  in  some  cases  of  hemiplegia  from 
fracture  of  the  skull.  More  frequently,  however,  anurias  are  due  to  reflex  in- 
hibition of  secretion.  It  appears  that  an  irritation  in  one  kidney  can  so  aifect 
the  other  organ  reflexly,  that  anuria  may  follow\  Thus  may  be  explained  the 
anuria  of  renal  colic,  following  operation  upon  the  kidney  or  injury  of  that 
organ.  Extensive  burns  may  also  produce  reflex  anuria,  although  the  absorp- 
tion of  toxins  may  have  something  to  do  with  these  cases  (Castaigne). 

In  hysteria,  the  anuria  is  probably  also  reflex,  although  the  exciting  cause 
is  not  always  apparent. 

(4)  Toxic  anurias  may  occur  in  the  course  of  infectious  diseases  such  as 
cholera,  scarlet  fever  and  in  acute  peritonitis  and  affections  of  the  colon  and 
small  intestines.  The  toxins  probably  act  by  affecting  the  renal  tissue,  as  well 
as  by  disturbing  the  circulation. 

B.  Obstructive  A:s^urias. — The  second  group,  the  obstructive  anurias,  are 
of  great  interest  to  the  modern  surgeon,  particularly  because  they  can  be  reme- 
died by  timely  intervention. 

They  result  either  from  the  blocking  of  the  lumen  of  the  ureter  or  from 
its  compression  or  kinking.  Among  the  obstructive  causes  w^e  have,  foremost, 
renal  calculi.  The  mechanism  and  pathologA-  of  this  form  of  anuria  has  been 
described  in  the  chapters  on  calculus  of  the  kidney  and  of  the  ureters,  respec- 
tively. It  has  been  said  that  it  is  not  necessary  to  have  a  stone  in  both  ureters, 
but  that  the  presence  of  stone  on  one  side  often  acts  reflexly  by  inhibiting  the 
secretion  of  the  opposite  kidney.  This  is  a  course  of  events  which  Guyon  has 
described,  but  it  is  probably  of  rare  occurrence.  In  most  instances,  the  anuria 
due  to  stone  on  one  side  arises  because  the  opposite  kidney  had  not  been 
working  for  some  time,  and  when  the  calculous  kidney,  which  alone  was 
capable  of  excreting  urine,  was  blocked,  a  total  suppression  of  urine  resulted. 
Albarran  has  gone  so  far  as  to  say  that  calculous  anurias  may  exist  without 
the  actual  presence  of  a  calculus  in  the  ureter  at  the  time  when  the  symptoms 
occur. 

Compression  of  the  ureter  may  produce  anuria  in  such  conditions  as  cancer 
of  the  bladder,  the  prostate,  the  uterus  or  the  kidney.  Kinking  of  the  ureter 
in  floating  kidney  may  be  accompanied  by  obstructive  retention  on  one  side  and 
arrest  of  secretion  on  the  other. 


CHANGES    IN    THE    AMOUNT    OF   URINE  275 

Symptoms. — Amiria  can  exist  for  a  long  time  witliont  giving  rise  to  any 
symptoms.  Jt  also  occurs  at  times  with  astonishingly  few  symptoms.  The 
phenomena  of  renal  insufficiency  and  of  uremic  poisoning,  which  are  described 
elsewhere  under  the  heading  of  Uremia,  come  either  slowly  or  suddenly,  ac- 
cording to  the  type  of  uremia,  acute  or  chronic,  which  develops  as  the  result  of 
the  suppression  of  urine.  Usually  the  first  symptoms  are  gastro-intestinal  in 
character,  including  nausea,  anorexia,  vomiting,  eructations  and  either  consti- 
pation or  diarrhea.  Headaches,  restlessness  and  other  nervous  phenomena  of 
uremia  are  also  among  the  early  symptoms.  Patients  with  anuria  may  die 
within  a  few  hours,  showing  the  acute  form  of  uremia  in  its  most  pronounced 
type.  They  may  also  live  for  days  and  even  weeks  without  showing  any  acute 
symptoms  and  linger  on  toward  a  slow  death  with  the  manifestations  of  chronic 
uremic  poisoning. 

The  occurrence  of  a  nonfunctionating  kidney  on  one  side  is  more  common 
than  it  is  generally  thought  to  be.  I  have  occasionally  seen  such  an  organ,  both 
larger  and  smaller  than  normal,  due  to  some  suppurative  process,  calculus,  tu- 
berculosis or  some  other  cause,  where  the  parenchyma  had  been  destroyed  and 
nothing  but  a  sclerosed  mass  or  shell  remained.  I  have  cut  into  such  kidneys 
at  operation  and  had  little  or  no  bleeding.  In  a  case  where  such  a  kidney  is 
present,  if  the  remaining  organ  is  suddenly  incapacitated,  an  attack  of  anuria 
would  occur. 

Diagnosis. — It  is  comparatively  easy  to  recognize  the  existence  of  anuria 
by  passing  a  urethral  catheter,  which  at  once  differentiates  this  condition  from 
retention.  The  important  point,  however,  is  to  determine  the  cause.  The 
first  thing  to  do,  if  possible,  is  to  determine  the  presence  and  seat  of  the  ob- 
struction. This  may  be  done  by  palpation  and  by  ureteral  catheterization. 
The  presence  of  obstruction  will  at  once  suggest  the  treatment  of  the  con- 
dition. 

If  the  anuria  be  transient  it  may  be  preceded  by  or  accompanied  with  a 
clinical  picture  of  renal  colic ;  or  there  may  be  a  history  of  traumatism,  or  of  an 
operation  either  on  the  abdominal  organs  or  upon  the  kidney. 

If  the  anuria  is  more  or  less  permanent,  we  should  first  exclude  the  pres- 
ence of  chronic  diseases,  such  as  affections  of  the  kidney  or  of  the  heart  or 
of  acute  infectious  or  toxic  conditions.  If  the  anuria  comes  on  suddenly, 
it  is  usually  due  to  calculi,  though  hysterical  anuria  should  not  be  lost 
sight  of. 

A  word  should  be  said  of  the  hysterical  type  of  anuria.  Usually  the  pa- 
tient presents  some  of  the  peculiarities  or  stigmata  of  hysteria.  Charcot  noted 
also  a  certain  compensation  between  the  anuria  and  the  vomiting  which  seemed 
to  alternate ;  thus,  when  the  patient,  who  was  a  woman,  urinated  3  grams  of 
urine,  she  had  1  liter  of  vomitus.  When  the  urine  increased  to  206  grams,  she 
vomited  only  362  grams.     Hysterical  anuria  is  a  tissue  anuria  and  not  ii'laudu- 


276 


SrKCIAL    UlMXAIiY    SY.MPT():\rS 


lar.  Til  other  words,  there  is  a  more  or  less  complete  suspension  of  the  proteid 
kataholic  function  of  the  digestive  epitheliuni  of  the  organism.  A  very  inter- 
esting and  rather  puzzling  feature  of  these  cases  is  that  hysterical  subjects  may 
liave  anuria  for  a  number  of  days  or  even  for  several  weeks  without  showing 
any  uremic  symptoms  whatever. 

Treatment. — The  medical  treatment  of  anuria  is  the  same  as  that  described 
elsewhere  under  the  heading  of  Uremia. 

Treatment  of  Obstructive  Anurias. — In  case  the  history  of  anuria 
points  to  a  surgical  cause — such  as  an  attack  of  renal  colic  on  the  one  side,  the 
passing  of  calculi,  pain  in  the  loin  on  one  side  for  a  considerable  time,  a  puru- 
lent urine  without  symptoms  of  frequency,  or  a  hematuria  following  exertion — 
the  case  should  be  immediately  examined,  not  only  by  palpation,  but  also  by 
cystoscopy  and  catheterization  of  the  ureters.  If  one  ureter  is  found  obstructed, 
even  though  the  other  catheter  enters  the  kidney,  an  incision  should  be  made 
in  the  loin  of  the  obstructed  side,  a  nephrotomy  performed,  the  pelvis  examined 
and  a  catheter  passed  down  the  ureter  to  the  seat  of  obstruction.  The  kidney 
should  then  be  drained  and  the  treatment  of  the  ureteral  obstruction  postponed 
until  the  patient  has  recovered  from  the  attack  of  anuria,  in  case  this  tem- 
porary operation  is  successful. 

The  result  of  the  hemorrhage  accompanying  the  operation  will  benefit  the 
patient  the  same  as  bleeding  in  uremia,  and  saline  solutions  can  be  given  by  the 
rectum,  or  into  the  tissues  or  a  vein,  as  indicated. 

Oliguria 

Oliguria,  or  diminution  in  quantity  of  urine,  is  noted  in  a  variety  of  patho- 
logical conditions,  affecting  either  the  urinary  .tract  or  the  general  system. 
Temporary  diminution  is  noted  in  health,  and  should  be  carefully  distinguished 
from  true  oliguria.  This  term  should  not  be  employed  unless  the  change  in 
the  amount  of  urine  is  well  marked  and  continues  for  several  days,  and  unless 
all  extraneous  causes  can  be  excluded. 

The  conditions  under  which  the  urine  is  diminished  in  quantity  in  health 
have  already  been  considered  under  the  heading  of  Urine  Analysis.  They  are 
briefly:  Exercise,  free  perspiration  and  not  drinking  sufficient  water.  In  dis- 
ease the  urine  is  diminished  in  acute  nephritis,  especially  after  scarlet  fever, 
in  acute  congestion  of  the  kidney,  in  the  acute  stages  of  chronic  nephritis  and 
often  in  the  last  stages  of  chronic  nephritis,  accompanied  by  uremia.  The  urine 
is  also  diminished  in  conditions  of  stasis  of  the  kidney  due  to  heart  disease. 
Among  the  general  conditions  which  produce  oliguria  and  which  are  important 
to  the  urologist,  are  shock  after  anesthesia  or  after  operations  on  the  genito- 
urinary organs.  Oliguria  is  also  noted  in  fevers,  where  it  is  accompanied  by  a 
concentration  of  the  urine.      Other  causes  of  oliguria  are  prolonged  diarrhea 


CHANGES    IN    THE    ClIAKACTEK    OF    TIIK    lUINE  277 

and  voinitiui;',  such  as  occiii's  in  some  diseases  as  cholera  or  yellow  fever.  The 
urine  is  markedly  diminished  in  quantity  in  all  diseases  in  the  last  stages  be- 
fore death. 


III.    CHANGES    IN   THE   CHARACTER   OF    THE   URINE 

Hematukia 

Definition. — Hematuria  means  the  admixture  of  blood  in  the  voided  nrine, 
no  matter  from  what  source  the  blood  is  derived.  Clinically,  the  term  is  ap- 
])lied  only  to  cases  in  which  the  amount  of  blood  is  such  as  to  be  perceptible  to 
the  naked  eye  on  inspection.  The  presence  of  a  microscopic  amount  of  blood 
is  not  clinically  styled  hematuria. 

Hematuria  must  be  carefully  distinguished  from  hemoglobinuria.  The  lat- 
ter means  the  direct  passage  of  the  blood-coloring  matter  into  the  urine  without 
any  red  blood  corpuscles,  the  urine  being  acid  and  of  lower  specific  gi-avity  than 
in  hematuria. 

Etiology. — The  causes  of  hematuria  are  many,  the  determination  of  which 
is  one  of  the  most  important  procedures  in  the  clinical  study  of  urinary  diseases. 

The  etiologic  factors  may  thus  be  briefly  summarized : 

ETIOLOGY     OF     HEMATURIA 

{Tabulated  after  Castaigne  with  Modification) 

I.   Traumatic  Hematuria. 

(a)    Wounds  and  Injuries  of  Any  Part  of  the  Tract. 
Rupture. 
Urethrotomy. 
Fracture  of  pubis. 
Wounds. 

Injuries  to  pelvis. 
Wounds. 
Injuries  to  loin. 
(6)   Stone  in  Any  Part  of  the  Tract:  Foreign  Bodies. 
Pelvis  of  kidney ;  ureter. 
Bladder. 

Posterior  urethra, 
(c)   Sudden  Change  of  Pressure  in  Bladder. 

When  a  bladder  is  emptied  too  suddenly  or  too  completely,  in  a  case  of  re- 
tention, we  may  have  bleeding  from  the  bladder  or  even  from  the  kidneys,  due  to 
congestion. 


278  SPECIAL   UKINARY    SYMPTOMS 

II.  Infammatory  II ematuria. 
Anterior  urethritis. 
Posterior  urethritis. 
Cystitis. 
Pyelitis,  acute. 

Acute  nephritis. 

Hemorrhagic  nephritis. 

Chronic  nephritis.     Some  types  in  which  vessels  are  changed. 

III.  Due  to  Tumors. 

(1)  Prostate. 

(2)  Bladder. 

(3)  Kidney. 

IV.  Due  to  Tuberculosis. 

(1)  Prostate. 

(2)  Bladder. 

(3)  Kidney. 

V.  Due  to  Parasites. 

Kenal  parasites ;  Bilharzia ;  Filaria,  etc. 

VI.  Due  to  General  Changes  in  the  Blood. 

Smallpox  Yellow  fever  Hemophilia 

Typhoid  Plague  Leukemia 

Purpura  ["Phosphorus  Malaria 

l^poisoning 

Detection  of  Hematuria. — This  has  been  considered  in  the  chapter  on 
The  Urine,  so  far  as  chemical  and  microscopic  tests  are  concerned,  but  there  are 
certain  gross  characteristics  to  hematuria  which  aid  in  its  detection  and  lo- 
calization. 

If  bloody  urine  is  allowed  to  stand  for  a  little  w'hile,  it  deposits  a  more  or 
less  abundant  sediment.  Over  this  there  remains  a  clearer,  but  still  cloudy, 
fluid.  This  may  be  bright  red  in  color,  showing  that  the  blood  has  been  freshly 
shed  and  that  it  probably  comes  from  the  lower  part  of  the  tract — from  the 
bladder  usually.  The  amount  of  blood  wall  determine  in  such  cases  the  exact 
tinge.  The  more  dilute  the  bleeding,  the  paler  the  tint,  but  fresh  blood  is  al- 
ways red. 

Renal  hematuria  is  characterized  by  a  pale,  reddish-brown,  cloudy  urine, 
the  sediment  containing  no  clots,  unless  they  are  wormlike  casts  of  the  ureters. 
If  retained  for  a  long  time  in  the  pelvis  or  in  the  bladder,  in  hematurias  asso- 
ciated with  obstruction,  there  may  be  a  dark-brown  or  even  black  color  to 
the  fluid. 

The  sediment  of  bloody  urine  varies  in  amount,  color  and  consistency.     The 


CHANGES    IN   THE    CHAKACTER   OF   THE   URINE  279 

first  thing  that  strikes  one  is  the  presence  or  absence  of  clots.  When  the  bleed- 
ing is  from  the  kidney  or  ureters,  the  clots  sometimes  assume  the  appearance 
of  dark-red  worndike  masses. 

Next  to  clots,  the  urine  may  sometimes  contain  a  bloody  sediment  mixed 
Avith  fragments  or  masses  of  tumors.  These  may  be  fibrinous  or  shaggy,  or 
they  may  appear  more  regular,  villous.  The  deposit  may,  of  course,  be  also 
mixed  with  fragments  of  crystalline  substance,  particles  of  calculi,  etc. 

When,  as  very  often  happens,  the  blood  is  mixed  with  pus,  the  deposit  as- 
sumes peculiar  stratifications.  In  some  cases,  the  deposit  of  yellowish-gray  pus 
is  arranged  in  strata  separated  by  bright-red  streaks.  This  means  that  a  layer 
of  pus  alternates  with  a  layer  of  blood  cells.  In  other  cases,  the  purulent  (usu- 
ally muco-purulent)  sediment  is  thick,  glairy  and  tenacious,  and  is  tinged  a 
distinct  red  color.  These  are  cases  of  alkaline  urines,  in  which  pus  has  under- 
gone the  glairy  change  into  a  viscid  mass,  as  the  result  of  the  action  of  the 
alkali.  In  these  cases,  the  urine  itself  is  but  feebly  tinged.  There  is  finally 
another  class  of  cases  in  wdiich  the  urine  is  bright  red  and  the  sediment  is  gray- 
ish or  gelatinous.  These  are  usually  cases  of  cystitis,  prostatic  abscess,  or  other 
purulent  infection  of  the  tract,  in  which  a  fresh  hemorrhage  has  taken  place  as 
the  result  of  some  existing  cause. 

Diagnosis  of  the  Cause. — The  diagnosis  of  the  cause  of  a  hematuria  is 
very  important  and  often  a  puzzling  problem.  The  question  is  easily  solved 
when  there  is  a  blood  disease  manifesting  itself  in  other  hemorrhages,  as  in 
purpura ;  when  the  urine  shows  signs  of  acute  nephritis,  oliguria,  high  specific 
gravity,  albumin,  casts,  etc. 

Hematurias  due  to  stone  are  often  characterized  by  an  intermittence  or  a 
remittence;  they  may  be  accompanied  by  pain,  and  are  worse  after  any  form 
of  exertion  or  jarring  motion,  while  hematurias  due  to  tumor  and  to  tuberculosis 
usually  occur  independent  of  either  pain,  exertion  or  jarring. 

To  sum  up: — The  cause  of  hematuria  must  be  determined  after  a  careful 
study  of  the  history  of  the  case,  a  thorough  examination  of  the  patient  and  a 
complete  analysis  of  the  urine.  If  these  precautions  are  taken,  one  will  seldom 
err  in  determining  the  pathological  process  which  gives  rise  to  the  bleeding. 

Localization  of  the  Bleeding. — Bleeding  fkom  the  Ukethea. — When 
there  is  bleeding  from  the  anterior  urethra  the  blood  oozes  or  drips  from  the 
meatus  independently  of  micturition.  But  when  the  blood  is  beyond  the  cut-off 
muscles,  the  blood  does  not  ooze  from  the  meatus,  but  is  voided  with  the  urine. 
The  two-glass  test  shows  blood  in  both  glasses,  the  second  more  than  the  first, 
because  the  muscular  effort  of  expulsion  brings  out  any  residue  of  blood  that 
may  be  present  in  the  posterior  urethra. 

Bleeding  fkom  the  Prostate. — Bleeding  from  the  prostate  is  also  char- 
acterized by  the  same  features.  In  bleeding,  either  from  the  prostate  or  the 
prostatic  urethra,  the  bladder  urine  may  also  be  bloody,  owing  to  the  regurgi- 


280  SPECIAL   URINARY   SYMPTOMS 

tation  of  the  blood  into  the  bladder.  The  di  fife  rout  ial  diagnosis  will  depend  on 
age,  history,  clinical  and  urinary  examination.  By  washing  the  bladder  through 
a  soft-rnbber  catheter  until  it  is  clean  and  then  filling  it  with  water,  if  the  fluid 
escaping  through  the  instrument  is  free  from  blood  while  the  remainder  voided 
is  mixed  with  blood,  the  source  of  the  hemorrhage  is  below  the  vesical  sphincter. 

Hemorrhage  from  the  Bladder. — Hemorrhage  from  the  bladder,  if  pro- 
fuse, gives  a  red  color  to  the  urine,  although,  if  collected  in  three  glasses,  the 
last  glass  will  contain  the  most  blood.  If  the  bladder  is  washed  clean  by  cathe- 
ter and  the  instrument  is  allowed  to  remain  in  place  for  a  short  time,  the  blad- 
der contents  will  again  become  bloody.  At  times,  the  last  drops  alone  contain 
fresh  blood.  Cystoscopy  will  usually  show  us  the  source  of  the  bleeding  if 
there  is  a  bleeding  point  in  the  bladder  or  if  it  comes  from  one  or  both  ureters. 

Bleeding  from  the  Ureter. — Bleeding  from  the  ureter  is  characterized 
by  the  elongated  clots  already  described,  unless  it  comes  from  the  vesical  end 
close  to  the  bladder. 

Bleeding  from  the  Kidney. — Bleeding  from  the  kidney  is  diagnosed  by 
excluding  all  other  sources.  The  blood  is  thoroughly  mixed  with  the  urine  in 
these  cases  and  there  is  no  separate  quantity  of  fresh  blood,  as  in  the  hemor- 
rhage farther  down.  In  the  three-glass  test,  the  patient  voids  a  uniformly 
tinged  urine  in  all  three  cases.  Microscopically,  in  renal  hematuria,  we  have 
blood  casts  and  renal  epithelia,  besides  the  fact  that  the  red  blood  cells  "  are 
washed  "  out  and  appear  as  swollen  shadow  disks  scarcely  perceptible. 

Having  located  the  bleeding  in  the  kidney,  we  must  next  try  to  find  out  the 
cause  of  the  symptom.  In  stone,  we  have  the  history  of  colic,  the  aggravation 
of  the  bleeding  after  exertion  or  jarring,  and  the  subsidence  of  it  after  days  of 
perfect  rest,  while  fragments  of  crystalline  masses  in  the  urine  will  often  clinch 
the  diagnosis. 

In  tumor  of  the  kidney,  we  have  bleeding  which  appears  and  disappears 
without  apparent  cause ;  emaciation ;  a  tumor  in  the  loin ;  increasing  pain ;  a 
feeling  of  weight ;  and  symptoms  of  pressure  and  a  varicocele  when  on  the  left 
side.  Cancer  cells  and  tumor  fragments  in  the  urine  would  complete  the 
diagnosis. 

In  tuberculous  K-idney,  a  polyuria  is  very  suggestive.  When  it  is  accom- 
panied by  renal  hematuria,  the  bleeding  recurs  without  apparent  cause.  Tu- 
bercle bacilli  may  sometimes  be  found  in  the  sediment.  It  is  difficult,  however, 
to  assigTi  a  definite  cause  for  the  early  hematurias  which  come  in  renal  tubercu- 
losis before  any  marked  changes  have  occurred  in  the  kidneys. 

In  nephritis,  large  numbers  of  red  blood  cells  always  indicate  the  acuteness 
of  the  condition.  In  some  cases,  renal  bleeding  occurs  without  previous  signs 
of  acute  or  chronic  nephritis.  (Perhaps  the  term  ''  essential  hematurias  "  is 
justified,  but  in  all  probability  there  is  some  basis  for  the  occurrence  of  the 
bleeding.)     Thus  a  number  of  cases  have  been  found,  after  nephrectomy,  to  be 


CHANGES    IN    THE    CHARACTER    OP^    THE    URINE  281 

early  stages  of  renal  tuberculosis,  and  in  certain  cases  there  were  found  the  signs 
of  a  chronic  interstitial  ne])hritis  with  arterial  changes.  Castaigiie  emphasizes 
the  value  of  studying  the  arterial  tension  in  such  cases.  If  the  tension  is  high, 
we  may  suspect  the  presence  of  interstitial  changes  in  the  kidney  in  cases  of 
otherwise  unexplainable  bleeding.  The  presence  of  even  slight  uremic  symptoms 
point  to  interstitial  nephritis  rather  than  to  other  causes  of  renal  bleeding. 

Which  of  the  two  kidneys  is  bleeding  is  usually  determined  nowadays  by 
cystoscopy  and  watching  the  urine  coming  from  the  ureters,  and  also  by  ureteral 
catheterization. 

ORDER    OF    FREQUENCY    OF    CAUSES    OF    HEMATURIA 

In  the  Clinic.  In  the  Hospital, 

Stricture.  Stone  in  bladder. 

Prostatitis.  Stone  in  kidney. 

Renal  calculus.  Tuberculous  bladder. 

Tuberculous  cystitis.  Tuberculous  kidney. 

Tumor  of  bladder.  Tumor  of  bladder. 

Prostatic  hypertrophy.  Stricture. 

]*^ephritis.  Prostatic  hypertrophy. 

Ulcer  of  bladder.  Rupture  of  kidney. 

Carcinoma  of  prostate.  Retention  of  urine. 

Seminal  vesiculitis.  JSTephritis. 

These  two  lists  simply  show  the  order  of  frequency  in  my  clinic  and  hos- 
pital. The  causes  would  have  been  very  different  if  taken  from  other  hospitals 
with  which  I  am  connected. 

Pyuria 

Pyuria  means  pus  in  the  urine  from  whatever  source.  Pyuria  may  be  due 
to  any  suppurative  inflammation  in  the  urinary  tract,  or  to  a  suppuration  in 
some  communicating  or  adjoining  organ.  It  is  one  of  the  most  frequent  symp- 
toms encountered  in  urologieal  practice. 

We  must  always  satisfy  ourselves  that  pus  is  actually  present  and  that 
we  are  not  mistaking  anything  else  for  it,  for  urine  passed  as  a  cloudy  fluid 
may  be  free  from  pus,  the  cloudiness  being  due  to  either  mucus,  bacteria,  plios- 
phates  or  urates. 

Differential  Diagnosis. — Every  practitioner,  therefore,  should  be  familiar 
with  the  rough  clinical  tests  which  are  necessary  to  determine  the  presence  of 
pus  immediately  after  the  urine  has  been  passed. 

Mucus. — formally  a  faint  mucous  cloud,  which  very  slowly  settles,  is  pres- 
ent in  the  urine.  It  consists  of  mucus  mixed  with  a  few  epithelial  cells  from 
the  bladder.     It  is  much  more  pronounced  in  women,  on  account  of  the  admix- 


282  SPECIAL   URINARY   SYMPTOMS 

ture  of  vaginal  imR'u.s.  It  is  markeclly  iiicroasod  in  catarrhal  cfinditions  of  the 
nrinary  tract,  especially  in  cystitis,  prostatitis  and  nrethritis. 

A  rough  test  for  mucin,  which  is  the  proteid  substance  contained  in  the 
mucous  cloud,  consists  in  diluting  the  urine  with  equal  parts  of  water  and  add- 
ing acetic  acid,  until  a  precipitate  of  mucin  is  formed  which  is  soluble  in  an 
excess  of  acetic  acid.  As  a  general  rule  mucus  may  be  distinguished  from  pus 
in  the  urine  by  the  fact  that  it  floats  longer,  is  less  dense  and  more  evanescent 
than  pus. 

Phosphates. — Phosphates,  when  present  in  excess,  or  when  the  urine  is 
slightly  alkaline,  create  a  diffuse  turbidity,  which  gradually  settles  on  standing. 
A  few  drops  of  acetic  acid  added  to  such  a  urine  will  almost  immediately  clear 
it  up,  while,  if  the  turbidity  be  due  to  the  presence  of  pus  or  mucus,  it  would  be 
increased  by  the  addition  of  the  acid. 

Bacteria. — Bacteria,  when  growing  in  large  numbers  in  the  urine  (see 
Bacteriuria),  give  rise  to  a  faint  cloud  wdiich  has  a  tendency  to  float  in  the  mid- 
dle part  of  the  vessel.  This  cloud  remains  practically  unchanged  by  the  addi- 
tion of  acetic  acid. 

Urates. — Urates,  when  present  in  excess,  form  a  turbidity  wdiich  rather 
rapidly  deposits  as  a  sediment.  The  lower  the  temperature  of  the  urine  and 
the  greater  the  acidity  (wdthin  certain  limits),  the  more  apt  are  urates  to  pre- 
cipitate. Simply  heating  a  test-tube  containing  such  a  urine  gently  over  the 
flame  will  dissolve  the  turbidity  and  clear  the  urine.  If  pus  w^ere  present  heat 
would  increase  the  turbidity  instead  of  decreasing  it. 

Chyluria. — Chyluria  may  be  mistaken  for  pyuria.  In  this  condition  the 
urine  is  milky,  yellowish-white  and  shows  a  iilm  of  fat  on  standing.  On 
shaking  with  ether,  the  fat  is  dissolved  and  the  urine  becomes  normal  in  ap- 
pearance. 

Pus. — Pus  in  the  urine  is  characterized  usually  by  a  cloudy  appearance 
immediately  after  passing.  The  cloudiness  is  usually  in  proportion  to  the  amount 
of  pus.  Small  amounts  of  pus  may  be  present  in  the  form  of  clumps  or  shreds, 
the  urine  reaiaining  comparatively  clear  at  the  time  of  passing. 

There  is  not  much  difference  in  the  appearance  of  purulent  urines  accord- 
ing to  the  locality  of  the  affection.  Urine,  clear  or  slightly  turbid,  with  thick 
threads,  points  to  the  urethra ;  urine  which  is  thick  and  turbid  and  tends  to 
become  gelatinous  on  standing,  points  to  the  bladder ;  urine  which  is  opaque 
and  not  thick,  but  ^viih  pus  held  in  suspension,  points  to  the  kidney.  If  it  is 
of  a  light  color,  a  lemonade  or  even  whiter,  it  is  probably  from  a  tubercular 
organ,  w^hile  if  it  is  darkly  colored,  it  points  more  to  a  calculous  kidney.  The 
light-colored  pyuric  urine  usually  occurs  when  there  is  considerable  polyuria 
wdth  pus  and  points  to  a  pus  kidney,  the  darker  when  the  urine  is  more  con- 
centrated or  bloody. 

The  color  of  the  urine  is  not  much  affected  by  the  presence  of  pus,  unless 


CHANGES    IN    THE    CHARACTER   OF    THE   URINE  283 

there  is  a  large  amount,  in  wliich  case  it  appears  whitisli-yell<nv  in  color  and, 
in  decomposing,  nrine  will  assume  a  dirty  gray  tint. 

The  odor  of  purulent  urine  may  be  either  normal,  when  the  urine  has  re- 
tained its  normal  acidity,  or  it  may  be  extremely  offensive,  putrescent  or  ammo- 
niacal,  or,  in  still  other  cases,  slightly  resemble  that  of  hydrogen  sulphid. 
Putrid  urine  occurs  principally  when  there  is  decomposing  residual  urine  in 
the  bladder  or  kidney. 

The  reaction  of  purulent  urine  varies  greatly,  according  to  the  amount  of 
decomposition  which  the  urea  undergoes  in  each  particular  case.  There  is  no 
specific  connection  between  the  reaction  and  the  localization  of  the  trouble. 
Formerly  it  was  believed  that  when  the  purulent  urine  was  alkaline  or  ammo- 
niacal,  we  had  to  deal  with  a  cystitis,  while  if  it  were  acid,  a  pyelitis  or  pyelo- 
nephritis was  present.  Further  advances  in  urology,  however,  have  shown  that 
ammoniacal  urine  may  be  obtained  with  the  ureteral  catheter  from  the  pelvis 
of  the  kidney. 

When  purulent  urine  undergoes  alkaline  fermentation,  the  pus  coagulates 
into  gelatinous  masses  which  adhere  to  the  bottom  of  the  vessel. 

Donne's  Test  for  Pus. — This  is  a  rough  clinical  test  which  is  of  great  aid 
to  the  2:)ractitioner  in  distinguishing  pus  from  mucus  and  other  sources  of  cloudi- 
ness. It  consists  in  allowing  the  sediment  to  gravitate  to  the  bottom  of  a  conical 
glass,  pouring  off  the  urine  which  floats  over  the  sediment,  and  adding  the  ordi- 
nary solution  of  caustic  potash  (jDotassium  hydrate),  drop  by  drop,  until  the 
gelatinous  tenacious  mass  mentioned  above  is  formed,  adhering  to  the  bottom 
of  the  vessel  and  slipping  out  of  it  en  masse. 

Localization. — Having  satisfied  ourselves  that  pyuria  is  present,  the  next 
step  is  to  determine  its  source.  This  we  do  in  several  ways.  First,  we  apply 
all  the  special  methods  of  clinical  examination  which  may  have  a  bearing  upon 
the  localization  of  the  trouble.  The  history  of  the  case  and  the  general  physical 
examination,  including  rectal  jialpation,  examination  of  the  urethra,  of  the 
l)ladder  and  of  the  ureters  through  the  catheterizing  cystoscope,  are  all  methods 
which  have  been  described  elsewhere  and  which  must  be  called  into  play  at  times 
in  determining  the  source. 

Before  we  proceed  to  the  special  methods,  however,  a  few  simple  clinical 
tests  should  be  applied  which  will  often  give  us  a  fair  idea  of  the  location  of 
the  pus : 

Thus,  if  we  can  express  it  from  the  meatus,  the  pus  is  evidently  urethral 
and,  in  man,  probably  comes  from  the  anterior  urethra.  ISText,  if  we  apply  the 
two-glass  test  and  the  first  urine  contains  pus  and  shreds,  and  the  second 
portion,  passed  immediately  afterwards,  is  clear,  it  is  evident  that  the  dis- 
charge is  of  urethral  origin.  If  the  first  and  second  urines  are  both  cloudy, 
it  shows  either  that  the  posterior  urethra,  in  the  male,  is  so  acutely  in- 
volved that  some  of  the  pus  overflows  into  the  bladder,  or,  what  is  more  prob- 


284  SPECIAL   URINARY    SYMPTOMS 

able,  that  there  is  an  iiivulveiuent  of  the  urinary  tract  ahove  the  vesical 
sphincter. 

When  the  ^vliole  amount  of  nrine  passed  is  found  to  contain  pus,  there  is  no 
doubt  that  some  affection  exists,  at  least  as  high  up  as  the  bladder,  if  not  higher. 
When  this  is  found  to  be  the  case,  the  special  methods,  such  as  cystoscopy, 
catheterization  of  the  ureters,  etc.,  may  he  applied,  in  order  to  localize  tlie 
trouble. 

Considerable  information,  however,  may  be  gained  regarding  the  case  aud 
a  probable  diagnosis  may  be  made,  from  a  detailed  urinary  examination  in  cases 
of  jDyuria,  provided  this  examination  is  made  by  an  expert  in  this  line  of  work. 
I  want  to  emphasize  strongly  the  need,  particularly  in  these  cases,  of  confining 
urinary  examinations  to  none  but  competent  men,  of  whom  there  are  compara- 
tively few^,  even  in  our  larger  cities. 

Attempts  have  been  made  to  determine  the  amount  of  pus  in  the  urinary 
sediment  by  counting  the  number  of  pus  cells  (Goldberg,  Posner).  This  method 
is  faulty,  because  the  pus  is  generally  very  unevenly  distributed  in  the  urines 
and  often  occurs  in  clumps  or  masses.  It  is  determined  with  sufficient  accuracy 
by  centrifugation  of  the  acidified  urine,  still  warm  (after  heating  it  to  assure 
the  solution  of  other  sediment),  in  a  tube  graduated  in  cubic  centimeters.  When 
the  urine  contains  much  pus,  the  sample  must  be  correspondingly  diluted,  be- 
fore centrifugation,  with  much  saline  solution. 

There  is  no  w^ay  of  telling,  from  a  study  of  the  pus  cells  found  in  the  urine, 
the  locality  from  which  they  come.  The  clew  to  the  localization  of  the  sujipu- 
rative  processes  occurring  in  the  genito-urinary  tract,  is  chiefly  the  study  of  the 
epithelial  cells  that  accompany  them,  and,  secondarily,  the  study  of  casts  and 
blood  corpuscles.  Although  it  is  true  that  there  are  always  some  cells  in  a 
urinary  sediment  whose  exact  origin  is  somewhat  doubtful,  the  majority  of 
epithelia  can  be  located  with  fair  accuracy  and  a  trained  observer  can  differen- 
tiate the  ejoithelial  cells  of  the  kidney  from  those  of  the  pelvis,  the  ureter,  the 
bladder,  the  prostate  and  the  urethra. 

When  the  bladder  alone  is  involved,  w^e  find  epithelial  cells  from  the  vari- 
ous layers  of  the  mucosa  of  that  organ  according  to  the  depth  of  the  lesions. 
In  ordinary  cystitis,  the  cells  from  the  superficial  and  middle  layers  only  are 
present.     When  there  is  ulceration,  the  deeper  layers  add  their  quota  of  cells. 

When  pyelitis  is  present,  whether  due  to  infection,  stone,  tuberculosis  or 
tumor,  a  considerable  number  of  pelvic  epithelia  will  accompany  the  pus. 

If  there  is  also  a  large  number  of  cells  from  the  bladder,  a  coincident  cys- 
titis exists,  which  may  have  been  the  primary  affection. 

When  the  kidney  is  involved  in  the  suppurative  process,  there  are  in  the 
purulent  sediment  many  epithelial  cells  from  the  renal  convoluted  tubules  or 
from  the  straight  collecting  tubules.  If  there  are  at  the  same  time  granular, 
epithelial,  pus  or  blood  casts,  we  are  dealing  Avith  a  suppurative  nephritis.     If, 


CHANCES    TN    TIIK    ClIAKACTER    OF    THE    TRIUNE  285 

in  addition  to  all  those,  there  ai'o  many  cells  from  the  I'eual  pelvis,  wo  have  to 
deal  with  a  pyclo-nephritis. 

If  the  pyuria  is  intermittent  or  remittent,  we  mnst  think  of  the  presence  of 
pyonephrosis  with  intermittent  obstruction  of  the  ureter,  as  stones,  or  a  pyo- 
ue])hrosis  in  movahh^  kidney. 

It  must  he  understood  that  these  diagnoses  are  based  on  the  recognition  of 
a  considerable  number  of  pus  cells  and  a  hirge  number  of  epithelia  from  some 
region  of  the  urinary  tract.  When  only  a  few  pus  cells  and  a  few  epithelia  are 
])resent,  we  are  probably  dealing  with  a  nonsuppurative  condition  or  merely 
with  a  congestion  or  irritation  along  the  tract. 

ISText  to  the  presence  of  epithelia,  the  occurrence  of  casts  is  important  in  the 
urinary  analysis,  as  it  speaks  for  the  involvement  of  the  kidney.  The  kidneys 
may  participate  in  the  suppurative  process  or  they  may  be  the  seat  of  a  secondary 
nephritis  of  the  nonsuppurative  type,  or  both ;  in  either  case,  casts  may  be  pres- 
ent. Whenever  there  are  pus  casts,  that  is,  casts  of  any  type  which  are  studded 
with  23US  cells,  renal  suppuration  may  be  diagnosticated  with  a  reasonable  de- 
gree of  certainty.  It  must  be  remembered,  however,  that  casts  are  not  always 
found  in  suppurative  nephritis,  any  more  than  they  are  in  the  nonsuppurative 
tj^pes  of  nephritis.  Their  absence,  therefore,  does  not  necessarily  exclude  the 
presence  of  suppurative  nephritis,  provided  that  pus  and  renal  epithelia  are 
present  in  sufficient  quantities. 

The  size  of  the  casts  varies  according  to  the  region  of  the  kidney  involved 
and  something  may  be  known  of  the  extent  of  the  process  from  this  feature. 
When  pus  casts  of  large  diameters  are  found,  we  know  that  the  nephritis  has  in- 
volved the  medullary  portion.  Casts  from  the  narrow  part  of  the  tubules  are 
smaller  in  diameter,  next  come  the  casts  derived  from  the  convoluted  tubules, 
and  finally  the  casts  from  the  straight  collecting  tubides.  When  the  smaller 
casts  from  the  convoluted  tubules  have  pus  cells  imbedded  in  them,  we  know 
that  the  cortex  has  been  reached  by  the  affection.  Larger-sized  plugs  of  pus 
from  the  calices  are  found  sometimes  in  pyelitis. 

Connective-tissue  shreds  when  present  in  the  urine,  accompanied  by  epi- 
thelia and  pus,  show  that  there  is  some  destructive  process  in  the  urinary  tract. 
When  the  epithelia  are  renal  and  the  sediment  also  contains  pus  casts,  the 
presence  of  connective-tissue  shreds  is  indicative  of  destructive  processes  in  the 
kidney. 

Having  thus  localized  the  pyuria,  some  further  points  in  the  urinary  exam- 
ination may  often  give  us  a  clew  as  to  the  cause  of  the  suppuration.  Thus,  if 
stone  be  the  cause,  the  unusual  abundance  of  some  form  of  crystals  or  the  occur- 
rence of  crystals  in  solid  masses  may  suggest  the  presence  of  a  calculus. 

If  tubercle  bacilli,  gonococci  or  other  microorganisms  are  found  in  the  sedi- 
ment, we  have  the  bacteriological  clew  to  the  jiyuria.  If  portions  of  tumors, 
such  as  papillomas  or  malignant  growths,  are  found,  a  correct  diagnosis  may 


286  SPECIAL   URINARY    SYMPTOMS 

sometimes  be  made  from  the  urine.     Unfortunately,  these  tumor  fragments  are 
not  frequently  encountered. 

Having  considered  the  urinary  report  in  detail  and  compared  it  with  the 
history  of  the  case  and  the  findings  of  the  physical  examination,  we  can  deter- 
mine that  a  suppurative  condition  exists  somewhere  in  the  urinary  tract,  that 
it  is  probably  due  to  either  obstruction,  stone,  tumor,  or  tuberculosis,  with  in- 
fection. If  the  urethra  is  involved,  it  may  be  detected  by  instruments;  if  the 
prostate,  it  may  be  felt ;  if  the  bladder,  it  may  be  seen  by  the  cystoscope ;  if  the 
ureter,  it  can  be  felt  by  the  catheter ;  if  the  kidney  or  pelvis,  the  ureteral  cathe- 
ters will  reveal  the  condition  and  the  side  involved,  by  the  character  of  urine 
draining  from  the  ureter, 

Pnetjmaturia 

The  term  pneumaturia  is  applied  to  the  evacuation  of  free  gases  in  the 
urine.  The  gases  are  formed  in  the  bladder,  or  they  may  enter  the  organ 
through  recto-vesical  and  vesico-sigmoidal  fistulas. 

According  to  Guiard,  the  production  of  COo  in  the  bladder  as  a  result 
of  alcoholic  fermentation  in  glycosuric  urine  is  one  source  of  pneumaturia. 
Miller  and  Senator  analyzed  the  escaping  gas  in  such  a  case  and  found  it 
to  consist  of  hydrogen  and  carbon  dioxid.  The  production  of  this  fermenta- 
tion in  the  bladders  of  diabetics  may  be  due  to  a  cystitis  produced  by  Bacillus 
coli  infection  (Schnitzler). 

When  a  cystitis  is  due  to  the  growth  of  gas-forming  bacteria,  such  as  the 
Proteus  vulgaris  and  allied  forms,  there  may  be  a  pneumaturia,  although  the 
urine  is  free  from  sugar.  Heyse  and  Favre  each  found  the  Bacillus  lactis 
aerogenes  in  a  case  of  pneumaturic  cystitis  without  glycosuria. 

The  gas  bubbles  are  usually  expelled  with  the  last  portions  of  urine.  If 
there  is  retention,  the  gases  may  accumulate  and  give  rise  to  a  false  sense  of 
vesical  emptiness  owing  to  a  tympanitic  resonance  over  the  bladder.  In  diabetic 
urine,  the  reaction,  even  after  this  fermentation,  is  acid ;  in  other  urines,  pneu- 
maturic fermentation  is  accompanied  by  alkalinity.  The  external  features  of 
the  urine  are  the  same  as  in  cystitis,  or  in  bacteriuria,.as  the  case  may  be. 

Gas  bubbles  have  been  found  at  autopsy  in  the  renal  pelvis,  and  the  walls 
of  the  bladder  have  been  found  the  seat  of  emphysema  in  several  instances. 

Bacteriuria 

Bacteriuria  is  a  condition  in  which  there  is  an  abundant  growth  of  pathogenic 
germs  in  the  urine,  but  in  which  there  is  very  little  evidence  of  an  inflammatory 
condition  of  the  urinary  tract.  Bacteriuria  is  generally  thought  to  be  asso- 
ciated with  some  lesion  along  the  urinary  tract. 

Robert,  in  1881    (Brit.  Med.  Jour.,  1881,   11,  p.   623),  was  the  first  to 


CHANGES    IN    THE    CHARACTER   OF    THE    URINE  287 

describe  it.     Since  llion  a  iiuniber  of  investigators,  notably  Krogius,  Kovsing, 
Jeanbraii,  Keyes  and  others  have  studied  this  condition. 

Pathology. — The  freshly  voided  urine  in  bacteriuria  contains  large  masses 
of  bacteria.  The  urine  is  cloudy,  sometimes  opalescent,  and  the  cloud  does  not 
settle,  but  on  shaking  assumes  wavy  motions  (Zuckerkandl).  If  there  is  a 
complicating  urethritis  or  prostatitis,  the  first  or  second  glass  may  also  contain 
pus  or  shreds,  but  often  the  glasses  contain  nothing  but  the  cloud  described. 
jSTo  albumin  is  necessarily  present,  but  the  reaction  for  mucin  with  acetic  acid 
is  obtainable.  The  urine  is  acid  in  reaction  and  has  a  foul,  fecal,  rather  than 
an  ammoniacal  odor.  The  microscope  reveals  large  masses  of  bacteria,  a  few 
epithelia  and  still  fewer  pus  cells  or  leucocytes. 

The  most  common  germ  found  in  bacteriuria  is  the  colon  bacillus  (in  83.5 
of  (u  cases  reported  by  Jeanbrau),  with  or  without  some  associated  staphylo- 
cocci (Barlow).  Less  frequently  are  found  the  streptococci,  the  proteus  of 
Hauser,  the  Bacillus  lactis  aerogenes  and  the  hydrogen-sulphid-forming  bacteria 
(Rosenheim  and  Guzman;  Karplus,  quoted  by  Zuckerkandl).  The  typhoid 
bacillus  which,  according  to  Richardson  and  Gwyn,  produces  bacteriuria  in 
twenty  to  thirty  per  cent  of  typhoid-fever  patients,  must  also  be  included  in 
this  group. 

In  most  cases,  the  infection  is  hematogenous  or  at  least  descending,  from 
the  kidney  and  the  pelvis. 

The  line  of  distinction  between  a  bacteriuria  with  a  few  pus  cells  and  many 
bacteria  and  a  mild  inflammation  of  some  part  of  the  urinary  tract  with  a  few 
more  pus  cells  and  less  bacteria  is  often  perplexing  to  the  practitioner.  The 
question  as  to  whether  parietal  lesions  in  the  urinary  tract  are  needed  for  the 
development  of  bacteriuria  is  still  disputed.  Most  authorities  say  that  such 
lesions  always  exist  and  that  the  mere  presence  of  bacteria  in  the  urinary  tract 
does  not  cause  bacteriuria,  as  has  been  shown  experimentally  by  the  injection 
of  bacteria  into  the  tract.  They  claim  that  besides  these  injections  a  parietal 
lesion  must  be  made  before  a  bacteriuria  develops. 

The  parietal  lesion  in  bacteriuria  is  not  in  the  bladder.  It  is  some- 
times in  the  prostate.  Krogius,  Hogge,  Goldenberg,  Gassman,  Keyes  and 
the  author  have  observed  such  cases.  It  is  usually  situated  in  the  ureter,  the 
kidney  and  its  pelvis,  although  the  lesion  may  be  unrecognizable  clinically. 
It  may  be  due  to  typhoid  infection,  to  the  puerperal  state,  or  to  prostatic 
hypertrophy.  Exceptionally  bacteriuria  is  said  to  be  due  to  prostatitis  and 
vesiculitis. 

Symptoms. — Certain  local  and  general  symptoms  have  been  ascribed  to  bac- 
teriuria. The  general  symptoms  may  be  due  to  the  colon  infection,  which  is  so 
often  present  in  these  cases.  They  are  lassitude,  headaches,  anorexia,  intestinal 
disturbances  and  at  times  a  febrile  movement.  Locally,  there  may  be  the 
symptoms  of  a  chronic  urethritis,  pyelitis,  prostatitis,  vesiculitis,  etc. 


288  SPECIAL  riiiXAKV  sy:\ipt():\is 

Treatment. — The  troatiuciit  consists  in  tlio  r('nio\-al  of  tlie  eanse  and  the  ad- 
ministration of  hexamethylenamin  (urotropin)  in  doses  of  seven  and  a  lialf  to 
ten  grains  three  times  daily.  Local  treatment  by  lavage  of  the  nreters  and 
pelvis,  by  washing  the  bladder  and  posterior  nrethra  and  by  massaging  the 
•prostate  and  vesicles,  is  also  indicated  according  to  the  source  of  the  trouble. 


CHAPTER  XII 

URINARY  FEVER  (CATHETER  FEVER),  URINARY  INFECTION 

The  older  authors,  among  them  Velpean,  Civiale  and  Thompson,  spoke  of 
urinary  fever  or  catheter  fever  as  a  form  of  natnral  reaction  of  the  body  to  the 
shock  or  irritation  induced  by  the  introduction  of  instruments  into  the  urinary 
tract.  It  was  thought  by  some  that  the  phenomena  of  urinary  fever  which  were 
chiefly  characterized  by  a  chill,  fever  and  sweating  were  of  nervous  origin. 
This  was  the  theory  of  Von  Dittel,  who  regarded  the  febrile  jDaroxysm  as  a 
reflex  process  induced  by  the  irritation  of  the  nerves  of  the  urethra.  Velpeau 
regarded  catheter  fever  as  a  form  of  systemic  poisoning,  in  virtue  of  the  en- 
trance of  urine  into  the  system  through  some  minute  injury  resulting  from  the 
instrumental  interference.  Thompson  distinguished  catheter  fever,  which  he 
divided  into  acute  and  chronic,  from  urinary  infection  proper,  which  he  styled 
pyemic  or  septicemic  fever.  The  idea  that  the  fever  following  urethral  in- 
strumentation was  of  nervous  origin,  held  sway  until  light  began  to  dawn  under 
the  influence  of  the  work  of  Oliver  "Wendell  Holmes  and  Semmelweiss  on  puer- 
peral fever  and  of  the  discoveries  of  Pasteur,  Lister  and  Koch. 

The  modern  definition  of  urinary  fever,  or  catheter  fever,  makes  it  synony- 
mous with  urinary  infection,  and  regards  it  as  always  due  to  the  entrance  of 
germs  or  their  toxins  into  the  blood.  The  normal  urine  in  a  healthy  bladder  is 
aseptic  and,  in  the  absence  of  a  urinary  or  general  infection,  the  urine  with- 
drawn after  death  has  been  repeatedly  shown  to  be  sterile.  Bacteria  become 
lodged  with  difficulty  in  the  normal  bladder  under  healthy  conditions.  When 
there  are  certain  predisposing  causes,  however,  such  as  congestion,  injury  to  the 
wall,  or  retention  of  urine,  bacteria  may  multiply  very  rapidly. 

The  routes  which  infection  may  take  from  the  urinary  tract  into  the  cir- 
culation are  numerous,  as  have  been  sliown  by  experiments  on  animals  and  by 
a  study  of  numerous  autopsies.  Thus,  it  has  been  shown  that,  under  favorable 
conditions,  germs  injected  into  the  bladder  can  pass  through  the  mucous  mem- 
l)rane  into  the  blood  and  kill  the  aniuuils  through  a  general  infection  without 
necessarily  ascending  to  the  kidney.  In  some  instances,  the  infection  in  the 
blood  penetrated  into  the  kidneys  and  septic  foci  were  found  in  the  latter  organs, 
although  the  ureters  and  pelves  of  the  kidneys  remained  free. 

The  urethra  may  also  be  a  ])ortal  of  entrance  for  a  general  infection,  espe- 

289 


290  URINARY   FEVER   AND   URINARY   INFECTION 

ciallv  after  instninicntal  interference.  It  has  Ijcen  shown  experimentally  tluit 
bacteria  could  be  found  in  the  blood  five  hours  after  the  introduction  of  an  in- 
strument through  a  stricture.  Bartelsmann  and  Mau  (Munchener  mediziniscJie 
Wocliensclirift,  1902,  p.  21,  quoted  by  Zuckerkandl,  loc.  cit.)  showed  that  in  a 
case  in  which  a  stricture  Avas  sounded  and  the  instrumentation  Avas  followed 
by  chills,  staphylococci  were  present  in  the  blood  during  the  chill  and  the  same 
variety  of  bacteria  were  found  in  the  urine. 

A  point  to  be  remembered  in  connection  with  urinary  infection  is,  that  even 
when  instruments  are  sterile  there  may  be  vesical  infection  through  carrying 
bacteria,  which  are  always  abundant  in  the  urethra,  into  the  bladder  (Mel- 
chior).  In  women  in  whom  the  urethra  is  wide  and  short,  there  may  even  be 
spontaneous  infection  of  the  bladder  from  the  healthy  urethra,  the  germs  pre- 
sumably coming  from  the  vulva. 

In  addition  to  this,  we  must  remember  that  there  are  two  other  ways  in 
which  germs  can  enter  into  the  urinary  tract.  One  is  through  the  kidneys  from 
the  blood,  and  the  other  through  the  intestinal  tract.  It  has  been  quite  thor- 
oughly established  by  experiments  (Biedl  and  Kraus,  quoted  by  the  latter  in 
Frisch  and  Zuckerkandl's  "  Handbuch  der  Urologie,"  vol.  1,  p.  444),  that  it 
is  not  necessary  to  have  a  lesion  in  the  kidney  in  order  to  have  bacteria  pass 
through  this  organ  from  the  blood  into  the  urine.  Biedl  and  Kraus  injected 
bacteria  into  the  blood  (Staphylococcus  aureus.  Bacterium  coli,  anthrax)  and 
recovered  them  within  an  hour  from  the  urine,  although  the  latter  contained 
no  blood  nor  albumin  and  the  kidney  was  perfectly  healthy.  Wyssokowitsch 
and  others  deny  the  possibility  of  bacteria  passing  through  the  healthy  kidney, 
but  it  is  probable  that  the  investigations  of  Biedl  and  Kraus,  Avhich  have  been 
confirmed  by  several  other  observers,  represent  the  actual  conditions.  A  lesion 
may  make  it  more  easy  for  bacteria  to  enter  the  urine,  but  its  presence  does  not 
seem  to  be  absolutely  necessary. 

Bacteria  can  pass  through  an  injured  intestine  into  adjacent  portions  of  the 
urinary  tract,  and  recent  investigations  have  shown  that  very  slight  lesions 
are  sufiicient  to  allow  the  Bacterium  coli  to  pass  through  the  intestinal  wall 
and  enter  the  urinary  tract.  Some  authors  have  even  gone  so  far  as  to  say 
that  this  transference  can  go  on  with  a  normal  intestine,  while  others,  as  Kraus, 
say  it  is  probable  that  no  bacteria  can  pass  through  the  normal  intestine,  and 
Markus  and  Faltin  (quoted  by  Kraus)  found  that  constipation,  produced  arti- 
ficially by  closing  the  anus,  was  not  sufficient  to  give  rise  to  a  passage  of  bacteria 
from  the  intestine  into  the  blood.  It  is  quite  generally  believed,  however,  that 
the  bacteria  from  the  intestine  may  in  constipation  either  pass  into  the  blood 
and  thence  into  the  kidneys  and  the  bladder,  or,  if  the  constipation  is  very 
chronic  and  especially  if  lesions  exist  in  the  intestine,  they  pass  directly  into 
the  bladder  from  the  gut. 

Having  thus  briefly  discussed  the  modes  in  which  infection  penetrates  into 


CLINICAL   TYPES    OF   URINARY   FEVER  291 

the  urinary  tract,  we  now  turn  to  the  exciters  of  infection  which  need  only 
be  mentioned  briefly  here,  as  they  have  been  considered  in  detail  in  the  chapter 
on  The  Bacteriology  of  the  Urine.  The  germs  which  are  concerned  in  urinary 
infection  are  the  same  as  those  found  more  or  less  frequently  in  pathological 
urine.  They  are  the  Staphylococcus  pyogenes  aureus,  albus  and  citreus ;  the 
Streptococcus  jDyogenes ;  the  Urobacillus  liquefaciens  septicus ;  the  Bacillus  pyo- 
cyaneus  and  the  Bacterium  coli  commune.  The  last-named  is  the  most  fre- 
quently responsible  for  urinary  infection,  while  the  staphylococcus  and  strepto- 
coccus come  next  in  frequency.  As  regards  the  gonococcus,  this  germ  itself  is 
really  not  considered  responsible  for  urinary  infection  as  such  and,  in  complicated 
cases  of  urethritis,  in  which  urinary  infection  occurs,  the  latter  is  usually  due 
to  the  associated  secondary  germs,  although  some  instances  of  general  infection 
with  the  gonococcus  have  been  reported  in  which  the  patients  died  of  peritonitis, 
septic  endocarditis,  etc.,  due  to  gonococcus  infection  ( JuUien,  "  La  Blennor- 
rhagie,"  Paris,  1906). 

Clinical  Types  of  Urinary  Fever. — The  clinical  forms  of  urinary  fever  may 
be  considered  under  two  general  headings,  the  acute  and  the  chronic  types. 
The  acute  form,  however,  may  be  clinically  subdivided  into  the  single  acute 
paroxysm  and  the  acute  prolonged  or  intermittent  form. 

Acute  Type  of  Urinary  Fever. — The  acute  paroxysm  of  urinary  infec- 
tion is  the  clinical  type  which  the  older  authors  knew  as  catheter  fever.  It  is  a 
type  which  is  most  distinctly  referable  to  a  true  blood  infection,  as  it  is  here 
that  microorganisms  have  been  most  often  found  in  the  circulation  both  in  the 
fulminating,  rapidly  fatal  cases,  and  in  the  acute  cases  followed  by  recovery. 

The  acute  paroxysm  occurs  either  without  warning  or  after  the  introduc- 
tion of  an  instrument.  The  time  which  elapses  between  the  instrumentation 
and  the  appearance  of  the  first  symptom  varies  between  several  hours  and  sev- 
eral days,  but  is  usually  a  few  hours.  The  first  symptom  is  a  severe  chill,  the 
patient  having  cold  extremities,  and  a  pale  and  cyanotic  look.  The  chill  varies 
in  duration  and  severity,  lasting  from  a  few  minutes  to  a  few  hours  and  may 
cause  the  patient's  teeth  to  chatter,  although  usually  it  is  not  so  severe  and 
there  is  simply  a  chilly  sensation.  The  respiration  may  be  irregular,  but  as  the 
chill  wanes  the  breathing  once  more  becomes  regular. 

The  next  symptom  is'the  fever,  which  rises  rapidly  with  frequent  and  tense 
pulse,  rapid  respiration  and  flushing  of  the  skin,  the  latter  being  hot  and  dry. 
The  rise  of  temperature  reaches  often  to  105°  F.  or  more  and  drops  (piite  rap- 
idly. The  fever  in  a  typical  case  is  followed  by  sweating,  beginning  ^\'ith  a 
slight  moisture  and  passing  into  a  profuse  perspiration.  After  the  sweating, 
the  patient  complains  of  fatigue,  headache  and  slight  stiffness  of  llie  limbs. 

In  some  cases,  there  are  also  during  the  attack  delirium,  diarrhea,  vomiting 
and  dyspnea.  The  delirium  may  accompany  the  chill  and  need  not  be  regarded 
as  important  at  this  stage.     The  mouth  and  tongue  are  dry,  especially  when  the 


292 


URmARY   FEVER   AND   URINARY   IXFECTIOX 


attack  is  a  repetition  of  a  preeedinf]^  one.     There  may  be  bilious   vomiting 

and  later  copious  fetid  stools.  Dnring  the  attack,  the  frequency  of  respira- 
tion may  be  accoiii])ani('d  by  a  sense  of  op- 
pression constituting  dyspnea.  Tiie  ])ulse 
is  usually  in-egular,  if  the  infection  is 
severe. 

The  single  acute  attack  just  described 
frequently  passes  away  in  a  few  hours,  l)ut 
it  may  last  two  or  three  days.  Usually  the 
shorter  the  attack  the  more  severe  it  is,  but 
these  single  attacks  are  rarely  fatal.  Deaths 
have,  however,  been  reported  following  a 
chill  which  resulted  from  such  a  slight  pro- 
cedure as  catheterization  of  a  strictured 
urethra.  In  these  fatal  cases,  the  chill  is 
prolonged  and  is  followed  by  collapse,  invol- 
untary defecation,  hiccough  and  gTadual  loss 
of  consciousness. 

It  is  scarcely  necessary  to  refer  to  the 
great  similarity  between  these  single  acute 
attacks  and  acute  malarial  paroxysms.  The 
resemblance  is  made  still  more  marked  by 
the  fact  that  the  acute  attack  may  be  re- 
peated after  an  intermission.  The  interval 
which  is  free  from  fever  is  variable  in  dura- 
tion and  the  number  of  attacks  also  varies.     Some  authors  claim  that  an  atypical 

first  acute  attack,  in  which 

the  stages  of  chill,  fever  and 

sweating  do  not  succeed  each 

other  regularly,  predicts  an 

intermittent   form   with   re- 
peated attacks  ;  but  this  rule 

is  not  to  be  relied  upon,  as 

frequently  the  acute  attacks 

described  above  do  not  run 

their  set  course. 

In     the     intervals,     the 

patients    may    suffer    from 

weakness,     irregular    pulse, 

loss   of   appetite   and   sleep, 

or  they  may  feel  perfectlv  ^     ^.^„     ,         -o  tt  tt 

•^  "^  '■  "  Fig.  22S. — Acute  Kecurring  Urixary  Fever. 

well.  Pyelo-nephritis  revealed  at  autopsy.     (After  Guyon.) 


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Fig.  227. — Acute  Urinary  Fever  after 
AN  Internal  Urethrotomy.  (After 
Guyon.)  These  recur  occasionally 
after  passing  sounds. 


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_ 

CLINICAL   TYPES    OF   URINARY   FEVER 


293 


The  acntc  attacks  may  also  assume  the  remittent  form  in  which  the  fever  is 
more  or  less  continuous  with  acute  exacerbations  accompanied  by  chills.  These 
are  severe  cases,  as  a  rule,  with  some  of  the  following  symptoms :  The  tempera- 
ture high,  with  delirium,  prostration  and  loss  of  consciousness,  with  a  dry 
tongue,  a  rapid  and  frequent  pulse,  vomiting,  hiccough  and  symptoms  of  bron- 
cho-pneumonia. Pustular  eruptions,  purpuric  patches  and  rashes  resembling 
erythenui  nodosum  sometimes  occur.  In  some  instances,  the  affection  assumes 
a  pyemic  form  with  suppurations  in  the  muscles,  joints,  cellular  tissue,  etc.  The 
parotid  sometimes  becomes  inflamed,  showing  that  the  urinary  infection  has 
involved  the  general  system.  All  these  local  suppurations  are  extreme,  and  per- 
sonally I  have  never  seen  an  involvement  of  the  parotid. 

The  prognosis  in  the  prolonged,  acute  type,  including  both  intermittent  and 
remittent  varieties,  should  be  more  guarded  than  in  the  primary  acute  form. 
Usually,  recovery  sets  in  from  one  to  three  weeks  after  the  first  paroxysm,  with 
a  gTadual  defervescence.  It  must  be  understood,  that  the  more  continuous  the 
fever  the  worse  the  prognosis  and  that  prolonged  fever  is  of  graver  import  than 
a  temporary  rise.  Kecovery  has  taken  place,  however,  even  in  cases  with  dis- 
seminated abscesses. 

CHKOjsric  Type  of  Ukinary  Fever. — The  chronic  type  of  urinary  fever  is 
a  frequent  form,  and  is  of  great  clinical  importance.  It  may  develop  primarily 
as  such  or  follow  the  acute 
form.  The  temperature  is 
limited  in  range  and  inter- 
mittent in  type,  the  eleva- 
tions being  moderate,  in 
contrast  to  the  sharp  rises 
in  the  acute  cases.  Fever 
is  not  always  present  and  in 
doubtful  cases  the  tempera- 
ture should  be  taken  at  fre- 
quent intervals. 

One  of  the  constant  and 
clinically  important  symp- 
toms of  this  form  are  di- 
gestive disturbances  with 
loss  of  appetite.  The  i)a- 
tients  lose  weight  and  be- 
come cachectic,  even  though  there  is  no  fever.  When  an  acute  attack  of  fever 
occurs,  as  it  does  sometimes  in  these  cases,  the  patient  becomes  prostrated  and 
keeps  his  bed  for  a  day  or  two. 

The  urinary  cachexia  persists  for  some  tiuic  and  oven  after  it  is  conquered 
the  patients  rcnuiin  dyspeptic   with  sallow  complexions  for   a  while.      If  the 


T       I     ^    3     4-5     6  _7_  8     9    10    (I    12   13    1^    i5-_  16    ;7 

_F     CMEMEMEMEMEnEMlEriEMEMEnEMEMEMEhEf^EME 
105.8   II 

\0H     4o _ 

fS.fc  37 ^- 


FiG.  229. — Chronic  Urinary  Fever,  Occurring  in  a  Case  of 
Incomplete  Retention  from  Prostatic  Hypertrophy. 
(After  Guyon.)  These  attacks  usually  follow  eatheteriza- 
tion,  but  may  occur  independent  of  it. 


294  URINAEY   FEVER   AND   URINARY   INFECTION 

cachexia  continues,  the  patients  die  of  exhaustion,  usually  with  uremic  symp- 
toms or  with  some  complication  or  intercurrent  disease.  The  chronic  form  of 
urinary  infection  is  especially  frequent  in  prostatics,  who  are,  however,  much 
improved  hy  regular  catheterization. 

The  prognosis  of  these  very  chronic  types  is  very  poor  and  especially  when 
the  cases  are  connected  with  chronic  suppurative  conditions  of  some  part  of  the 
tract  involving  gTadually  the  kidneys. 

In  general,  the  prognosis  may  be  said  to  vary,  no  matter  what  the  type  may 
he,  according  to  the  virulence  of  the  germs,  the  duration  of  the  infection  and  the 
nature  of  the  urinary  lesions  present.  If  the  obstruction  to  the  urinary  flow 
can  be  removed  surgically  and  the  patient's  urinary  tract  can  be  made  to  drain 
well,  the  progTiosis  becomes  brighter.  In  the  chronic  forms,  the  infection  has 
usually  become  so  generalized  and  has  affected  the  system  so  deeply  that  the 
prognosis  is  naturally  least  favorable. 

Treatment  of  Urinary  Fever. — The  first  consideration  is  prevention.  This 
consists  in  so  handling  our  cases  during  examination  and  treatment,  that  n<j 
infection  can  occur.  For  the  most  trivial  surgical  procedure,  the  strictest  asep- 
sis must  be  maintained,  according  to  the  principles  laid  down  in  the  appropri- 
ate chapter.  Certain  preventive  measures  may  be  adopted  also  before,  during 
and  after  surgical  maneuvers  on  the  urinary  tract.  In  preparing  for  such  pro- 
cedures, one  of  the  essentials  is  rest.  Patients  who  arrive  in  an  exhausted  con- 
dition from  travel,  overwork  or  loss  of  sleep,  should  have  one  or  more  good 
night's  rest,  under  the  influence  of  a  mild  hypnotic  if  necessary.  The  bowels 
should  be  thoroughly  moved  and  a  large  amount  of  water  should  be  drunk  in 
connection  with  a  urinary  antiseptic,  as  urotropin. 

Just  before  the  examination,  especially  if  the  patient  has  pus  in  the  urine, 
a  suppository  containing  morphin  (gr.  ^)  and  quinin  (gr.  10)  should  be 
given,  together  with  an  additional  dose  of  urotropin  (gr.  1.5).  The  examina- 
tion itself  should  be  carried  on  under  the  local  influence  of  a  weak  solution  of 
cocain  and  should  the  patient  begin  to  tremble,  perspire,  clutch  the  table,  con- 
tract the  limbs,  show  a  spasmodic  contraction  of  the  sphincter  muscles,  complain 
of  pain  or  start  to  bleed,  it  is  well  to  postpone  the  remainder  of  the  examination 
until  another  time.  A  small  catheter  should  then  be  inserted  and  the  bladder 
filled  with  1 :  3,000  silver  solution,  which  the  patient  should  be  allowed  to  i)ass 
out  afterwards.  It  is  advisable  not  to  resort  to  cystoscopy  until  the  patient 
can  well  tolerate  an  ordinary  instrumental  examination.  If  tolerance  is  not 
established  with  the  aid  of  cocain,  general  anesthesia  may  be  needed  for  an  ex- 
amination of  the  urethra  and  bladder. 

I  have  found  that  most  of  the  cases  of  urethral  fever  that  have  followed 
examinations  in  the  ofiice,  the  clinic  or  the  hospital,  occurred  in  patients  who 
have  had  too  much  instrumentation  at  the  first  visit,  in  other  words,  where  too 
much  haste  has  been  used  in  examining.     In  the  office,  it  has  usually  been  in  the 


TREATMENT    OF    URINARY    FEVER  295 

cases  tluit  have  come  from  out  of  town,  accompanied  by  their  physician,  when 
both  wanted  to  return  on  the  same  day.  In  the  clinic,  it  was  usually  in  the  in- 
teresting cases  in  which  it  was  necessary  to  complete  the  examination  in  one 
visit,  as  otherwise  the  patient  might  not  return. 

Haste  in  examination  is  a  very  bad  practice.  Business  men  should  be  dis- 
couraged from  having  their  cases  rushed  through  as  quickly  as  possible  to  save 
time.  The  only  cases  in  which  haste  is  needed  are  those  of  retention  of  urine 
and  uremia.  In  retention,  the  preliminary  treatment  should  be  at  once  applied, 
including  urotropin,  a  suppository  of  morphin  and  quinin  and  a  hot  sitz  bath. 
The  treatment  for  retention  of  urine,  w^hich  has  been  outlined  elsewhere,  is  then 
to  be  systematically  followed  until  relief  is  effected.  As  soon  as  thorough 
drainage  is  established,  the  symptoms  of  urinary  infection  will  usually  begin  to 
improve,  and  the  patient  has  a  good  chance  of  recovery  if  the  urinary  flow  is 
maintained  together  with  the  other  necessary  therapeutic  measures. 

In  operating  on  the  urinary  tract,  certain  precautions  should  be  taken  to 
prevent  urinary  infection.  Free  drainage  should  always  be  established.  In 
external  urethrotomy  operations,  the  parts  should  be  frequently  flushed  with 
boric-acid  solution  and  afterwards  hydrogen  peroxid  should  be  injected  through 
the  urethra  and  allowed  to  escape  through  the  perineal  opening.  The  bladder 
may  also  be  washed  out  with  a  1 :  10,000  solution  of  bichlorid.  Wherever  pos- 
sible, drainage  tubes  or  catheters  should  be  employed  in  such  a  manner  as  to 
protect  cut  surfaces  from  contact  with  urine.  In  the  after  treatment  of  opera- 
tions, the  urethra  and  bladder  should  be  washed  at  least  twice  daily  and  the 
attendants  should  see  that  the  drainage  tubes  act  properly  and  constantly. 
Special  precautions  should  always  be  taken  against  infection  in  passing  in- 
struments through  strictures,  and,  after  the  instrument  has  been  introduced, 
the  bladder  should  be  filled  with  silver  solution  or  some  other  antiseptic 
fluid,  which  the  patient  should  be  instructed  to  pass  out,  thus  washing  the 
urethra. 

Treatment  of  the  Attack. — During  the  acute  attack,  the  patient  is 
wrapped  in  blankets  when  the  chill  comes  on  and  given  hot  and  alcoholic  drinks 
to  provoke  perspiration.  A  small  dose  of  quinin  should  be  at  once  given  and 
repeated  as  indicated.  The  bowels  should  be  moved  and  the  urinary  condition 
should  1)0  carefully  looked  after.  Retention  of  urine,  urethritis,  cystitis,  pye- 
litis and  nephritis,  should  be  treated  according  to  the  rules  laid  down  in  the 
appropriate  chapters. 

In  the  chronic  cases,  the  treatment  should  be  chiefly  directed  toward  the 
gastro-intestinal  tract.  The  patient  should  be  ]iartly  on  a  milk  diet  and  should 
receive  frequent  doses  of  laxatives.  The  digestive  function  should  be  stimulated 
by  small  doses  of  whisky  and  bitter  tonics.  Bathing,  followed  by  frictions  to 
stiiiiuhito  the  secretory  functions  of  the  skin,  are  also  useful  in  some  cases. 
Three  grains  of  quinin  tliree  times  a  day  usually  benefit  the  patient  consider- 


296  URINAKY    FEVER    AND    URINARY    IXKECTION 

ably.  Whisky  is  iu  my  hands  another  vahiable  roniedy  and  the  patients  are 
given  from  two  to  six  ounces  a  day,  depending  on  the  seat  of  the  infection. 
When  the  lesion  is  below  the  kidnej',  the  doses  are  larger.  Citrate  of  caffein,  in 
doses  of  from  one  to  three  grains  three  times  a  day,  is  also  very  beneficial  when 
the  patient  is  in  a  weak  septic  condition. 


CHAPTER    XIII 
THE   HISTORY  OF   THE   CASE 

A  THOKOUGH  consideration  of  tlie  history  of  a  urinary  case  is  essential  in 
making-  an  accurate  diagnosis.  It  is  well,  as  a  rule,  to  allow  the  patient  to  tell 
his  or  her  story  first,  interrupting  only  to  bring  out  more  clearly  points  of  in- 
terest that  might  have  an  important  bearing  upon  the  condition.  It  is  advisable 
then  to  take  the  history  in  a  systematic  way,  both  in  order  to  make  it  easier 
of  interpretation  and  to  have  the  records  that  will  be  of  value  for  future  study. 
I  will,  therefore,  present  herewith  a  copy  of  the  cards  (Figs.  230  and  231)  that 
I  am  in  the  habit  of  using  for  men  and  women  respectively,  showing  the  meth- 
ods that  I  have  employed  for  a  number  of  years  in  a  large  hospital  clinic  and 
in  my  private  practice. 

It  is  my  intention  to  present,  first,  a  brief  consideration  of  each  of  the  head- 
ings in  my  history  chart  and  the  important  points  they  bring  to  the  surgeon  for 
consideration,  and  to  outline  the  steps  of  the  routine  examination  of  a  case  in 
the  office.  In  other  chapters  I  discuss  more  in  detail  individual  symptoms  and 
groups  of  symptoms  observed  in  urology. 

Age. — The  age  of  the  patient  is  very  important  as  pointing  to  the  various 
diseases  that  may  occur  at  certain  periods  of  life.  In  children,  we  have  but  few 
urinary  troubles.  If  there  are  any,  they  are  due  to  congenital  stricture,  espe- 
cially near  the  meatus,  to  the  irritation  of  a  tight  prepuce,  to  some  nervous 
afi'ection  or  to  vesical  stone;  all  of  which  give  rise  to  frequency  of  urination  and 
the  last  named  to  some  pain  and  tenesmus. 

As  the  individual  grows  older,  the  diseases  of  youth  arc  to  bo  considered, 
principally  due  to  gonococcus  infection  and  tuberculosis  of  the  urinary  tract. 
The  varieties  of  the  complications  of  these  two  infections  arc  numerous,  involv- 
ing the  urethra,  bladder,  ureter  and  kidney,  as  well  as  the  genitals  in  both  sexes. 

In  early  manhood  and  womanhood  tuberculosis  is  still  connnon ;  calculus  is 
more  connnon  than  in  the  earlier  jjeriods ;  the  gonococcus  infections  are  slightly 
less  common,  while  their  results — stricture,  cystitis  and  diseases  of  the  internal 
genitals  (the  prostate  and  vesicles  in  men  and  the  uterus  and  tubes  in  women)  — 
are  more  often  brought  to  our  attention.  Uterine  and  renal  displacements  are 
more  connnon  in  women,  as  well  as  urinary  troubles  dependent  on  childbirth. 

297 


298 


THE   HISTORY   OF    THE    CASE 


In  iniddlo  life,  tuberculosis  is  less  frequently  met  with,  as  are  also  the  acute 
gonococcus  infections.  Stricture  of  the  urethra  is  more  common,  while  kiduev  and 
bladder  troubles  occur  with  about  the  same  frequency  as  in  early  manhood,  as 


Diagnosis 


Age 


Referred  by 


OccupatK 


NatKJty 


Family   History 


Past  History 


ent  History 


Principal  Symptoms 


Discharge 


Character  of  Urination 


Character  of  Urine,  (pus,  blood) 


EXAMINATIOM 


I  Genitals 


\  Discharge  (smear) 


Stand-    /Urine  1st 


Lying- 


Bladder 


Urine  4th,  (residual) 


Kidneys 


LABORATORY    REPORT    ON    URINE   AND    DISCHARGES 


Clear  or  Cloudy,  Colo 


Sp. 


Albumin 


Sugar 


Crystals 


Connective  tissue 


Microorganisms 


Epithelia 


Casts 


Discharge  (smear) 


Remarks  on   Urine  and   Discharges 


Fig.  230. — Male  History  Card. 


do  also  the  bladder  affections  depending  on  diseases  of  the  spinal  cord  and 
brain. 

In  old  age,  prostatic  changes  occur,  associated  with  vesical  and  renal  symp- 
toms of  a  surgical  nature.  Malignant  tumors  and  calculi  are  more  frequently 
found.  Changes  in  the  kidney,  due  to  circulatory  disturbance,  take  place  with 
increased  frequency;  while  tuberculosis  and  the  diseases  dependent  on  gono- 
coccus infection  are  not  so  common  as  in  earlier  life. 

Occupation. — To  know  the  patient's  occupation  is  useful  in  determining  the 
possible  effects  of  .traumatism  or  of  continuous  muscular  effort,  the  frequency 
of  exposure  to  cold,  wet  and  other  influences  of  the  weather,  and  the  general 
mode  of  life,  sedentary  or  otherwise. 


KACE 


299 


Civil  State. — Tn  men,  the  civil  state,  whether  single  or  inarried  or  widower 
has  a  certain  bearing  upon  some  urinary  diseases,  especially  those  connected 
with  sexual  disturbances.      Thus  gonococcus   infections   are   more   common   in 


Referred  by 


Occupation  Nativity 


If  Married  when?  No.  of  Children  - 


Family   History 


Past  History 


Present  History 


Principal  Sympton 


Pain 


"Discharge 


Character  of  Urination 


Character  of  Urino,  (pus,  blood) 


Menstruation  (charactfr  of) 


Kidneys 


.Externa  lii^Ilim. 


I  Dischare^e 


,  Urine  1st 


.lnternali_2l!:i!L 


Bladder 


,  Urine  (residual) 


LABORATORY    REPORT    ON    URINE    AND    DISCHARGES 


Clear  or  Cloudy,  Color Odor Reaction  Sp. 

Alb'J"'''" Sugar Urea Indican  Tot; 


Crystals 

Mucus 

Connective  tissue 

Red   Blood 

White 

Microorganisms 

Epithelia 

Casts 

Other 

feat 

ures 

Discharge  (s 

mear) 

Remarks  on   Urine  and   Discharges 


Fig.  231. — Female  History  Card. 


single  people;  congestion  of  the  prostate,  prostatitis  and  vesiculitis,  from  an 
irregular  sexual  life,  are  more  common  in  widowers,  men  in  the  army  and  navv, 
travelers  for  business  houses  or  men  in  other  callings  where  for  various  reasons 
the  sexual  life  is  not  well  regulated. 

In  women,  the  question  of  marriage,  childbirth  and  abortion  has  an  obvious 
bearing  upon  the  diseases  of  the  genital,  and,  indirectly,  of  the  urinary  tract, 
as  causing  displacements  and  the  prolapse  of  the  bladder  (cystocele),  as  well 
as  disturbed  bladder  functions  due  to  diseased  adnexa. 

Race. — The  patient's  nativity  or  race  has  uiuch  to  do  with  the  prevalence  of 
certain  urinary  diseases.  Thus,  iu  Spani.sh-Ainericans,  stricture,  prostatitis,  stone 
and  nephritis  are  most  connnon  ;  impotence  in  men  and  nephroptosis  in  women. 


300  THE   HISTORY   OF   THE    CASE 

In  the  Italians,  we  find  a  prevalence  of  stone  and  tnberculons  lesions.  In 
the  Jewish  race,  diabetes  and  bladder,  prostatic  and  seminal  vesicle  disturbances 
are  to  be  looked  for. 

Family  History. — The  family  history  of  the  patient  is  the  next  heading  to 
be  filled  out  on  our  card.  Certain  urinary  diseases  seem  to  be  influenced  by 
heredity.  The  uric-acid  diathesis,  with  its  tendency  to  deposit  crystalline  masses 
and  to  form  stones,  is  unquestionably  found  very  frequently  in  successive  gen- 
erations. Bright's  disease,  arteriosclerosis,  diabetes,  diseases  of  the  spinal  cord 
and  brain,  hysteria  and  neurasthenia  with  their  special  disturbances  in  the  uri- 
nary function,  are  all  unquestionably  influenced  by  heredity.  The  existence  of 
tuberculosis  in  the  family  will  always  lead  to  a  suspicion  of  tuberculous  urinary 
lesions  if  the  symptoms  of  a  chronic  process  in  the  urinary  tract  are  present, 
even  though  the  lungs  of  the  patient  show  no  trace  of  tuberculous  lesions. 

It  is  said  that  there  is  no  hereditary  predisposition  to  prostatic  hypertrophy ; 
but  I  have  noticed  the  occurrence  of  the  disease  in  members  of  the  same  family 
and  prostatics  have  occasionally  told  me  that  their  fathers  had  had  the  same 
trouble.  The  same  is  said  to  be  true  of  strictures,  to  which,  according  to  Thomp- 
son, there  seems  to  be  a  family  predisposition. 

Cancer  of  the  kidney,  the  prostate  and  bladder  is  another  disease  in  which 
the  heredity  is  to  be  carefully  investigated.  The  predisposition  to  malignant 
tumors,  when  present,  goes  far  toward  making  us  watchful  for  the  presence  of 
such  growths  in  the  urinary  tract. 

Past  History. — When  inquiring  for  data  to  be  written  under  this  heading, 
we  begin  at  childhood,  asking  as  to  the  occurrence  of  infectious  diseases.  The 
occurrence  of  scarlatina,  diphtheria,  etc.,  will  make  us  think  of  possible  nephri- 
tis. The  various  diseases  gone  through  at  an  early  age  to  the  present  day  should 
be  noted.  Rheumatic  attacks  are  associated  with  the  uric-acid  diathesis  or 
stone ;  protracted  coughs  point  to  tuberculosis ;  attacks  of  renal  colic  indicate  a 
stone.  These  are  among  the  phenomena  to  be  considered  in  the  past  history. 
The  occurrence  and  number  of  attacks  of  urethritis  make  us  look  for  stricture, 
prostatitis,  cystitis  and  renal  affection ;  while  syphilis  points  to  bladder  affections 
through  atony  of  its  walls  due  to  a  spinal  sclerosis.  Traumatism  and  urological 
or  other  operations  are  also  to  be  noted,  if  they  have  occurred,  as  they  have  im- 
portant bearings  on  the  etiology  of  the  present  affection. 

Present  History. — Having  thus  elicited  by  a  few  leading  questions  the 
heredity  and  past  history  of  our  patient,  we  come  to  the  consideration  of  the 
present  illness,  i.  e.,  of  the  complaint  for  which  the  patient  needs  our  assistance. 
Here  it  is  usually  best,  in  order  to  obtain  a  consecutive  story,  to  ask  when  the 
patient  last  felt  perfectly  well.  Beginning  with  this  data,  with  a  little  urging, 
the  leading  events  of  the  illness  will  be  related  to  us,  which  we  write  down  in 
a  condensed  form  on  the  lines  following  the  heading  "  present  history." 

The  patients,  in  relating  their  present  history,  will  usually  speak  of  j-jain. 


PRINCIPAL    SYMPTOMS  301 

disturbed  mietiirition,  a  discharge,  the  presence  of  blood  in  the  urine,  or  the 
passage  of  nrine  which  they  describe  as  "  not  being  clean."  They  may  also 
complain  of  inability  to  attend  to  their  work,  not  only  on  account  of  urinary 
disturbances,  but  also  on  account  of  a  feeling  of  weakness  or  sickness.  Patients 
who  complain  of  weakness  and  sickness,  which  may  be  constant  or  intermittent, 
may  be  suffering  from  some  constitutional  trouble,  as  a  nephritis,  a  carcinoma 
or  tuberculosis.  When  such  a  condition  occurs  in  the  form  of  attacks,  it  may 
be  due  to  a  congestion  in  some  part  of  the  urinary  tract,  to  febrile  attacks  due 
to  impediment  to  the  escape  of  pus,  and  to  other  causes  which  they  cannot 
account  for.  Loss  of  weight  is  generally  due  to  the  condition  or  diseases  just 
mentioned.  As  the  leading  symptoms,  however,  are  those  which  I  at  first  out- 
lined, I  will  take  them  up  more  in  detail ;  and  these  are  so  important  that  I 
have  placed  them  on  the  card  (see  Figs.  230  and  231),  in  order  that  I  may  not 
omit  any  of  them  in  taking  the  history  of  the  case. 

Principal  Symptoms. — The  first  thing  to  be  asked  after  the  patients  have 
given  us  their  version  of  the  present  illness  is.  What  is  the  principal  symptom — 
i.  e.,  the  one  complaint  that  has  led  to  the  visit?  The  answer  to  this  question 
will  often  tell  us  what  the  disease  is ;  as,  for  instance,  discharge  will  lead  us 
to  believe  that  the  patient,  if  a  man,  has  a  urethritis,  especially  if  it  is  associated 
with  a  burning  on  urination,  alone  or  associated  with  frequency ;  or,  if  a  woman, 
that  it  comes  from  her  urethra  or  vagina.  A  hemorrhage  from  the  urinary 
tract  will  lead  us  to  think  of  tumor.  The  passage  of  dirty  urine  will  lead  us  to 
think  of  pyuria.  A  sudden,  sharp  pain  darting  down  the  ureter  will  indicate 
renal  calculi  passing  down  the  tract,  etc, 

Pahst. — In  the  great  majority  of  cases,  pain  is  one  of  the  symptoms,  if  not 
the  leading  symptom,  complained  of.  The  subject  of  pain  in  urinary  diseases 
is  discussed  more  at  length  under  the  heading  of  Symptomatology.  In  taking 
the  history,  the  duration,  character,  intensity,  localization,  chief  seat  and  direc- 
tions of  pain  should  be  noted.  The  relation  of  pain  to  rest  and  motion,  exercise 
or  jarring,  micturition,  defecation  and  to  the  sexual  organism,  are  also  points  of 
interest. 

The  character  of  pain  complained  of  by  patients  with  urinary  diseases,  varies 
considerably  from  the  acute,  colicky,  sudden,  sharp  pain  of  stone  traveling 
down  the  ureter,  to  the  feelings  of  discomfort,  dullness,  heaviness,  or  of  an  in- 
describable irritation  of  an  indefinite  kind  in  some  locality. 

Pain  in  the  loin  may  mean  involvement  of  the  kidney  and  may  be  either 
surgical  or  medical.  The  diseases  one  must  look  for  when  pain  in  the  loin  is 
present  are  renal  stone,  tuberculosis,  tumors,  movable  kidney,  nephralgia,  peri- 
nephritic  abscess,  pyelitis  and  pyelo-nephritis.  The  pain  in  the  loin  is  usually 
in  the  back,  on  one  side,  beneath  the  free  border  of  the  ribs,  although  it  may  also 
be  found  in  the  corresponding  situation  in  front,  or  beneath  the  angle  of  the 
ribs,  in  the  ileo-costal  space. 


302  THE    HISTORY   OF   THE    CA8E 

The  character  of  the  ])ain  may  be  sharp,  as  in  the  passage  of  calculi,  or  of  tu- 
bercular accuuiulations,  in  movable  kidney,  or  in  nephralgia  from  nephritis. 
In  these  same  conditions,  a  dull  pain  may  be  present,  or  a  heaviness,  as  in  tumor 
of  the  kidney.  These  pains  may  radiate  down  the  ureter  in  the  direction  of  the 
groin  or  bladder,  especially  in  cases  of  stone. 

Pain  in  the  ureter  is  reflected  up  toward  the  kidney,  or  downward  towai-d 
the  bladder  or  testes.  It  may  also  have  a  point  of  maximum  severity,  as  in  a 
displaced  kidney,  the  pedicle  of  which  has  become  twisted  at  a  certain  point 
(Dietl's  crisis),  or  in  the  presence  of  calculus;  the  larger,  rougher  and  more 
jagged  the  stone,  the  more  acute  is  the  pain. 

Suprapuhic  pain  is  usually  dull  and  accompanied  by  a  sense  of  pressure 
and  fullness.  It  is  most  marked  in  cases  of  sudden  retention  of  urine,  when 
there  is,  in  addition,  a  cramplike  feeling.  It  may  also  be  present  in  inflamma- 
tion sf  the  bladder  from  any  cause,  as  from  extensions  from  the  urethra,  stone, 
tuberculosis  or  tumor  of  the  bladder,  being  more  marked  and  more  acute  in 
cystitis  due  to  stone  and  tuberculosis.  A  sense  of  discomfort  or  fullness  in 
the  suprapubic  region  is  frequently  due  to  an  involvement  of  the  seminal 
vesicles. 

Pain  in  the  groin,  in  the  male,  points  to  trouble  with  the  testes,  the  cord 
or  with  the  seminal  vesicles.  In  women,  it  means  involvement  of  the  ad- 
nexa.  If  the  pain  is  of  a  dull  character,  it  is  due  to  inflammation  of  the  sem- 
inal vesicles.  When  there  is  pressure  on  the  ejaculatory  duct  on  one  or 
both  sides,  from  prostatic  inflammations,  pain  in  the  groin  may  also  be  pres- 
ent. Pain  in  the  groin  is  elicited  wdien  the  vas  deferens  is  inflamed,  or  the 
ampulla  alone  is  involved.  In  epididymitis,  due  to  the  extension  from  the 
urethra  along  the  vas  deferens,  pain  in  the  groin  precedes  the  pain  in  the 
epididymis. 

Pain  in  the  perineum  in  the  male  is  usually  due  to  stricture,  deep-seated 
urethritis,  posterior  urethritis,  acute  or  chronic  prostatitis,  or  prostatic  hyper- 
trophy or  Cowperitis.  In  women  it  usually  points  to  laceration  of  the  perineum 
or  hemorrhoids. 

Discharge. — This  symptom  will  be  studied  more  in  detail  in  the  chapter 
on  the  subject.  In  taking  the  "  present  history,"  however,  one  of  the  symptoms 
complained  of  is  often  a  discharge.  In  men,  we  inquire  as  to  the  amount,  the 
character  and  time  of  occurrence  of  the  discharge.  If  profuse  and  purulent, 
it  points  to  an  acute  urethritis ;  if  very  scanty  and  mucoid,  it  indicates  a  chronic 
process.  When  the  discharge  is  associated  with  defecation  and  is  glairy  or 
glycerinlike,  it  is  due  to  prostatorrhea  or  spermatorrhea.  In  women,  a  thick 
discharge  coming  from  the  vagina,  called  by  some  vaginitis,  is  generally  asso- 
ciated with  leucorrhea  and  endometritis,  and  wdien  accompanied  by  burning  on 
urination,  points  to  a  urethritis.  In  both  cases,  if  acute,  the  gonococcus  should 
be  looked  for. 


PKINCIPAL    SYMPTOMS  303 

Character  of  Urination. — Under  this  heading-,  the  two  chief  points  to 
be  considered  are  the  frequency  of  voiding  urine  and  any  difficulty  or  irregu- 
larity in  voiding  it. 

Frequency  of  urination  is  one  of  the  most  important  symptoms  to  be  con- 
sidered in  urinary  surgery,  and,  next  to  pain  and  discharge,  is  the  one  princi- 
])ally  complained  of.  Frequency,  more  marked  during  the  day,  in  men,  points 
to  stricture,  posterior  urethritis,  prostatitis,  vesiculitis,  cystitis  and  vesical  cal- 
culus ;  in  women,  it  indicates  cystitis,  vesical  calculus,  urethral  stricture, 
urethral  caruncle,  uterine  displacement  and  growths,  and  adhesions  due  to  dis- 
eases of  the  adnexa.  Frequency,  occurring  principally  at  nig'ht,  indicates  pros- 
tatic hypertrophy  and  prostatitis,  in  men ;  in  women,  pressure  on  the  bladder 
in  certain  cases  of  uterine  disease,  as  fibroma  or  carcinoma.  Tuberculosis  of 
the  bladder  causes  frequency  of  urination  both  day  and  night  in  both  sexes. 
Tenesmus  at  the  time  of  urination,  points,  in  men,  to  an  acute  inflammation  of 
the  posterior  urethra,  of  the  vesical  neck ;  to  an  acute  prostatitis ;  to  a  prostatic 
hypertrophy  with  congestion  or  cystitis ;  to  a  stricture ;  to  vesical  calculus ;  or 
tuberculosis.  In  women,  it  points  to  cystitis,  calculus  and  tuberculosis  of  the 
bladder,  or  urethral  caruncle. 

Difficulty  in  passing  urine,  in  men,  points  to  obstruction  as  prostatic  hyper- 
trophy or  stricture ;  to  vesical  calculus,  or  to  atony  of  the  bladder  from  sclerosis 
of  the  cord  or  lesions  giving  rise  to  paralysis.  In  women,  the  same  causes 
may  give  rise  to  difficulty,  except  prostatic  hypertrophy,  and  with  the  addition 
of  cystocele,  uterine  displacements  and  prolapse  and  adhesions  to  the  bladder, 
holding  it  out  of  its  normal  position.  Retention  and  incontinence  of  urine  will 
be  discussed  in  detail  in  the  chapter  on  these  subjects. 

Character  of  the  Urine. — The  patient's  impression  as  to  the  character 
of  the  urine  is  set  down  under  this  heading.  It  enables  us  to  elicit  the  probable 
presence  of  blood  (hematuria),  of  pus  (pyuria),  of  a  milky  substance  (chy- 
luria),  of  a  brick-red  sediment  (uraturia),  of  ammoniacal  fermentation  (cys- 
titis), or  of  sulphurous  odor  (cystinuria,  pyelo-nephritis).  Furthermore,  a 
general  idea  of  the  quantity  voided  (oliguria,  anuria,  polyuria),  may  also  be 
obtained  from  the  patient's  statement. 

Character  of  the  Menstruation. — On  the  female  card  will  be  seen  the 
question,  "  Character  of  Menstruation  %  "  This  is  not  of  such  great  importance, 
but  is  of  some  significance,  for,  although  the  genital  tract  in  the  female  is  not 
in  such  close  contact  with  the  urinary  as  in  the  male,  nevertheless  they  are  suf- 
ficiently associated  for  us  to  consider  the  function  of  the  main  genital  organ. 
An  increased  flow,  or  frequency  of  flow,  from  the  uterus  might  mean  a  fibroid 
tumor,  an  endometritis,  or  a  malignant  growth.  A  cessation  of  flow  might  in- 
dicate pregnancy,  tuberculosis  or  change  of  life.  Uterine  pain  would  indicate 
endometritis  and  displacement,  all  of  which  might  have  an  important  bearing 
on  the  bladder  of  the  female. 


CHAPTER    XIV 

GENERAL  SYMPTOMS 

Before  proceeding  to  tlic  iirological  examination,  wliich  is  outlined  on  the 
chart  (Figs.  230  and  231),  the  general  symptoms  should  be  considered  and  a 
general  examination  made,  more  or  less  minute,  according  to  the  nature  of  the 
case.  A  surgeon,  even  if  he  devotes  himself  largely  or  exclusiveh''  to  urological 
conditions,  should  not  neglect  to  study  his  patient's  general  condition  in  every 
case,  and  thus  avoid  that  evil  of  specialization,  the  overlooking  of  important  gen- 
eral features,  in  the  concentration  of  his  thoughts  ujDon  the  local  condition.  The 
patient's  appearance,  nutrition,  gait  or  posture,  the  condition  of  the  tongue, 
the  character  of  the  pulse,  the  rate  of  respiration,  the  size  of  the  pupils,  are 
all  signs  which  offer  important  diagnostic  data  and  which  should  never  he 
neglected. 

(1)  Nutrition.— The  size  and  weight  of  the  individual  is  important  from 
several  view  points.  For  instance,  tall,  spare  persons,  especially  women,  are 
more  liable  to  have  movable  kidneys,  whereas,  this  affection  is  usually  absent  in 
shorter  and  heavier  persons.  The  reasons  for  this  are  fully  discussed  in  Chapter 
XXII.  Progressively  decreasing  weight,  in  other  words,  emaciation,  may  point 
to  diabetes ;  or  when  accompanied  by  local  urinary  disturbances,  to  chronic  sup- 
purative or  tuberculous  diseases  in  that  part  of  the  genito-urinary  tract.  A  loss 
of  weight  is  also  incident  to  certain  types  of  chronic  nephritis,  whereas,  an 
extreme  form  of  cachexia  w^ould  make  us  suspect  malignant  disease. 

Obesity  sometimes  accompanies  the  earlier  stages  of  diabetes.  Increase  of 
weight  with  edema  would  at  once  naturally  call  attention  to  renal  diseases.  It 
may  be  noted  that  increase  of  weight  and  good  muscular  development  is  not  in- 
compatible with  the  presence  of  nephritis,  even  in  an  advanced  degree;  and  that 
tuberculosis  of  the  kidney  in  its  initial  stages,  and  also  when  the  kidney  is  half 
destroyed,  is  seen  at  times  in  individuals  in  apparently  perfect  health. 

(2)  The  Skin. — So  far  as  the  color  of  the  skin  is  concerned,  a  waxy  pallor 
is  quite  characteristic  of  amyloid  kidney,  while  lesser  degrees  of  pallor  occur  in 
chronic  nephritis.  Pallor  with  a  hectic  flush,  points  to  tuberculosis,  while  with 
pufiiness  of  the  eyelids,  it  points  to  renal  diseases.  The  pallor  of  the  face  of  gin 
drinkers,  so  frequently  seen  in  England,  is  typical  of  the  nephritis  occurring  in 
these  types  of  alcoholics.     Hepatic  disorders,  especially  those  couunon  to  indi- 

304 


ODOR  305 

\i(lii;ils  coiniiiii,'  from  llic  1i'()])ic*s,  are  cliaracterizod  l)y  a  ycllowisli,  sallow  hue. 
In  some  diabetic  })alients  the  skin  is  also  yellow  and  peculiarly  dry.  A  sallow, 
yellowish  tint  is  also  seen  in  chronic  malaria,  while  a  bronzed  hue  is  character- 
istic of  diseases  of  the  suprarenal  capsule. 

Alonii;  with  the  color  of  the  skin,  we  note  the  condition  of  the  mucous  mem- 
brane. The  latter  is  pale  in  anemic  conditions,  while  the  presence  of  cyanosis, 
represented  by  blue  lips  and  livid  finger  nails,  would  point  to  badly  compensated 
heart  disease  so  frequently  associated  wdth  renal  affections. 

There  are  a  few  eruptions  of  the  skin  wdiich  can  be  connected  with  urinary 
disease.  In  diabetes,  we  frequently  find  furuncles  and  carbuncles,  wdiile  in  the 
advanced  stages  gangrene  may  occur.  Pruritus  occurs  in  nephritis  and  diabetes. 
Ecthymatous  eruptions,  which  are  sometimes  seen  on  the  legs  or  on  other  parts 
of  the  body,  occur  in  patients  with  constitutional  disease  which  lowers  the  vital- 
ity of  the  skin,  such  as  nephritis,  syphilis,  tuberculosis,  alcoholism,  etc. 

(3)  Posture. — The  posture  and  the  gait  of  the  patient  may  sometimes  be  of 
value  in  diagnosis.  In  ascites,  or  abdominal  tumors,  we  have  a  peculiar  gait, 
Avith  the  body  bent  backward  and  the  feet  spreading  widely  to  aid  in  the  support 
of  the  added  weight.  In  locomotor  ataxia,  the  well-known,  peculiar  gait  and 
the  inability  to  balance  oneself  with  the  eyes  closed,  is  of  interest  in  connection 
with  cases  of  retention  of  urine  and  difficult  micturition,  accompanying  lesions 
of  the  cord.  Patients  wdth  partial  hemiplegia  walk  with  a  dragging  of  one  ex- 
tremity and  their  urinary  symptoms  are  at  once  referred  to  the  central  nervous 
system.  Patients  walking  with  a  stooping  posture,  or  limping  so  as  to  favor 
one  side,  may  be  suffering  from  renal  colic,  from  perinephritic  abscess,  from 
inguinal  adenitis  or  from  epididymitis. 

The  position  of  the  patient  in  bed  in  renal  colic  and  in  perinephritic  abscess, 
is  such  as  to  avoid  the  contact  of  anything  with  the  painful  parts.  Usually 
the  body  is  bent  laterally  toward  the  diseased  side.  In  active  renal  colic,  the 
thighs  are  flexed  and  even  the  upper  part  of  the  trunk  is  bent  toward  the  source 
of  the  pain.  In  acute  prostatitis  and  in  abscesses  about  the  rectum,  the  thighs 
are  drawn  up  and  the  patient  sits  on  one  buttock,  although  he  prefers  usually 
a  reclining  position.  In  vesical  pain  and  difficulty  in  passing  water,  the  patient 
may  squat  while  in  the  act  of  micturition,  or  stand  clutching  for  some  support 
and  straining  to  pass  water.  These  are  but  a  few  examples  of  the  various  pos- 
tures assumed  characteristically  by  patients  with  urinary  disease. 

(4)  Odor. — An  abnormal  odor  discernible  on  apjiroaching  the  patient  some- 
times gives  us  a  clew  regarding  the  trouble.  Thus  an  aunnoniacal  odor  points 
to  incontinence  of  urine,  usually  from  some  obstruction,  such  as  stricture  or 
prostatic  enlargement  or  from  atony  of  the  bladder  due  to  diseases  of  the  spinal 
cord.  A  necrotic  odor  points  to  the  presence  of  sloughing  or  gangrenous  condi- 
tions affecting  the  lower  part  of  the  tract,  or  to  sloughing  venereal  ulcers  or 
warts. 


306  GENERAL   SYMPTOMS 

(5)  General  Behavior. — The  g-enoral  Ix'liavior  of  the  patient  is  often  of 
value  in  leading  iis  into  the  I'iglit  channel  for  diagnosis.  Xenrasthenic  patients 
exhibit  a  peculiar  uneasiness,  with  j^urjjoseless  movements,  such  as  shifting  the 
legs,  etc. ;  they  easily  flush  and  pale  imder  questioning,  their  speech  is  at  times 
thick  and  hesitant.  In  hysteria,  a  vague  absent-minded  expression  of  the  face, 
a  lack  of  consecutive  expression  of  thought,  a  rambling  speech,  often  very  volu- 
ble, and  either  extreme  anxiety  or  an  unaccountable  levity  are  noted  by  the 
physician.  In  sexual  neurasthenia,  there  is  usually  a  touch  of  melancliolia  and 
a  hypochondriacal  tendency  to  exaggerate  all  symptoms  and  to  draw  a  very 
dark  picture  of  the  complaint.  Thus,  from  the  very  appearance  of  the  patient, 
we  are  often  led  to  think  of  the  possibility  of  disturbances  in  the  genital  organs 
connected  with  urinary  disease. 

In  bed-ridden  patients,  the  condition  of  the  mind  in  such  states  as  uremia, 
urinary  fever  and  sepsis  needs  attention.  The  details  will  be  found  in  the 
appropriate  chapters.  Here  we  may  mention  merely  the  confusion  of  ideas, 
the  drowsy  apathy  and  the  gradual  clouding  of  sensation  in  uremia. 

(6)  The  Tongue. — The  patient's  tongue  -has  a  bearing  upon  the  general  con- 
dition, though  it  may  not  necessarily  show  anything  connected  with  his  urinary 
organs..  We  may  mention,  however,  the  dry,  coated  tongue  of  the  typhoid  state 
accompanying  septic  conditions  (urinary  fever,  septicemia,  pyemia),  and  that 
a  dry  tongue  should  always  indicate  a  serious  condition  in  urinary  diseases, 
before  as  well  as  after  operations  on  the  urinary  organs. 

(7)  Pulse  and  Temperature. — The  pulse  and  temperature  are  to  be  taken 
in  every  case  in  which  constitutional  trouble  is  suspected.  A  rapid  pulse  with 
high  tension  would  lead  us  to  think  of  renal  trouble,  although  a  patient  may  have 
normal  blood  pressure  when  uremic ;  a  pulse  increased  in  rapidity  but  not  in 
tension,  is  found  in  urinary  fever  or  sepsis.  A  feeble  pulse,  a  dicrotic  and  easily 
compressible  pulse,  or,  on  the  other  hand,  a  bounding  pulse,  may  be  seen  in 
valvular  affections  of  the  heart  complicating  nephritis. 

Whenever  fever  is  found  to  be  present,  w^e  should  first  of  all  seek  the  source 
of  the  rise  of  temperature  by  making  a  careful  routine  examination  of  the 
urinary  tract.  The  blood  should  be  examined  for  malaria  and  typhoid  fever 
when  fever  occurs  for  any  length  of  time.  Many  patients  are  treated  for  malaria 
for  a  long  time  when  in  reality  they  are  suffering  from  suppurative  renal  dis- 
eases or  from  complicated  renal  calculus.  Fever  occurring  in  a  patient  leading 
a  catheter  life  or  after  other  instrumentation,  would  at  once  arouse  the  sus- 
picion of  urinary  fever  or  sepsis ;  the  same  may  be  said  of  fever  occurring  after 
an  operation  on  the  urinary  tract.  Acute  febrile  attacks  in  patients  with  urinary 
disease,  who  have  previously  been  in  apparently  good  health,  usually  point  to 
the  prostate  gland,  some  complication  of  the  urethra  or  the  kidney.  In  the 
ordinary  form  of  nephritis,  there  is  no  elevation  of  temperature;  but  there  is 
a   distinct  febrile  movement   in   the   suppurative  nephrites,    including   pyelo- 


EESPIKATION  307 

iicplirilis,  ])_y(me])lirosis,  abscess  of  llic  kidney  and  stone  or  tiil)ercnlopis  in  iIk; 
kidney  conipiicalcd  hy  secondary  infection,  etc.  In  abscess  of  tlu;  kidney,  the 
teni])eratnre  may  range  from  09°  to  105°  F.,  falling  abrnptly  when  the  abscess 
ru])tnres.  In  pyelo-nephritis,  the  range  is  lower  and  the  type  more  chronic. 
In  ]iyonephrosis,  the  type  is  often  of  a  remittent  typhoid  character  or  so 
markedly  intermittent  as  to  simnlate  malaria.  When  the  pus  is  discharged  from 
the  kidney  after  having  been  retained  for  a  time,  there  is  a  remittance  or  an 
intermittence  of  fever.  In  snppnrative  conditions  of  the  kidney  in  which  there 
is  a  sndden  obstruction  to  the  outflow  of  pus,  as  in  stone,  the  fever  may  set  in 
sharply  with  a  chill,  followed  later  by  sweating. 

In  perinephritic  abscess,  the  patient  runs  a  septic  temperature  with  all  its 
characteristics,  including  great  emaciation.  Movable  kidney  may  also  be  ac- 
companied by  chills  and  fever,  occurring  from  time  to  time  if  pyelitis  is  present. 
In  acute  nephritis,  there  may  be  an  onset  of  chills  and  fever  and  a  rise  of  tem- 
perature throughout  the  disease. 

There  is  no  characteristic  temperature  in  uremia.  When  this  condition  is 
associated  wdth  acute  or  chronic  inflammatory  or  suppurative  states  in  the  kid- 
ney, the  fever  of  the  nephritis  dominates  the  scene.  A  subnormal  tem]:)erature 
may  be  observed  during  the  uremic  attack  itself. 

In  prostatic  inflammations,  a  rise  of  temperature  may  be  noted,  especially 
in  the  acute  form  of  prostatitis,  which  is  usually  ushered  in  by  a  chill.  During 
the  abscess  formation,  profuse  sweating  may  take  place,  especially  at  night. 
Cases  of  chronic  abscess  of  the  prostate  may  be  unaccompanied  by  fever,  or 
only  give  rise  to  a  very  slight  febrile  movement.  In  periurethral  inflammations, 
sepsis  of  a  varying  degree,  with  or  wathout  chills,  shows  itself,  depending  on 
the  extent  and  character  of  the  inflammation.  Sweating  generally  accompanies 
these  cases.  The  presence  of  both  pus  and  urine  in  the  cellular  tissue,  as  in  cases 
of  urinary  extravasation,  gives  rise  to  the  most  severe  and  fatal  sepsis. 

(8)  Respiration. — The  rapidity  and  character  of  the  respiration  may  be  al- 
tered in  the  course  of  certain  urinary  diseases.  Marked  dyspnea  may  accom- 
pany chronic  interstitial  nephritis,  especially  in  uremic  patients.  Eajiid  and 
shallow  respiration  may  be  noted  in  perinephritic  abscess,  after  injuries  of  the 
kidney  (rupture  of  the  organ),  or  as  a  result  of  the  pressure  of  a  large  kidney 
upon  the  diaphragm.  The  Cheyne-Stokes  breathing,  noted  in  interstitial  nephri- 
tis with  heart  disease  and  in  advanced  cases  of  uremia,  must  also  be  mentioned. 
C'oni])licating  pleurisies  or  broncho-pneumonias,  such  as  occur  in  septic  jiatients, 
will,  of  course,  increase  the  rapidity  and  alter  the  character  of  the  breathing. 


CHAPTER    XV 


EXAMINATION   OF   PATIENTS 


It  is  my  desire  in  this  chapter  to  outline  the  steps  in  the  examination  of 
male  and  female  patients  in  as  nniform  a  manner  as  possible.  The  resnlt  of  my 
stndy  of  the  different  methods  of  examination,  in  hospital,  clinic  and  private 
practice,  has  led  me  to  ontline  the  following  system  as  being  at  present  the  most 
convenient  for  the  nniform  nrological  examination  of  male  and  female  patients. 
Donbtless  in  the  near  future,  as  this  specialty  develops,  better  methods  will  be 
established. 

rKOLOCHCAT.      EXAMINATION^      OF      PATIEXTS 

Position  of  Patients  during  Examination 


(1)  Patient  at 
■  fnll     lei 
on  table 


fnll     length 


(2)    Patient 
standing 


(3)  Patient  at 
fnll  length 
on  table 


Male 

Abdomen. 
Kidneys. 
Bladder. 

External  genitals. 
Discharge  (smear). 

f  1st  nrine, 
I    2d  nriiie. 
<    Prostate. 
I    Vesicles. 
t  3d  nrine. 

{Urethra. 
Bladder. 
4th  urine  (residual). 


Female 

(1)  Patient  at    f  Abdomen, 
full     length  <  Kidneys, 
on  table  t  Bladder. 

In    gynecolog-     f  External  genitals, 
ical  position    [^  Discharge  (smear). 

(2)  Patient    r  1st  urine, 
on  commode  1    2d  urine. 


(3)  Patient  in 
gynecologic- 
al     position 
on  table 


''  Uterus. 
Tubes. 
Ovaries. 
Urethra. 
Bladder. 
3d  urine  (residual). 


Examination  of  the  Abdomen. — When  the  abdomen  is  examined,  the  pa- 
tient should  lie  on  the  table  full  length,  with  the  legs  extended  (Fig.  232).    The 
examination  of  the  abdomen  is  practically  the  same  in  both  sexes.     The  upper 
zone,  including  the  liver,  stomach,  spleen  and  kidneys,  is  first  palpated,  and 
308 


EXAMINATION   OF   THE   ABDOMEN 


309 


LABOKATOKA^    KKi'ORT    ON    UKINE    AND    DISCHARGES 


Clear  or  cloudy. 

Color. 

Odor. 

Reaction. 

Specific  gravity 

Albtnuiu, 

Sugar. 

Urea. 

Indican. 

Total  solids. 

Crystals. 

]\riicns. 

Counective  tissues. 

Red  blood. 

White. 

llicroorganisins. 

Epithclia. 

Casts. 

Other  features. 

Discharge 

(sinear) 

Remarks  ou  urine  i 

iiid  discharges 

: — 

Treat. 

then  the  lower  zone,  including  the  suprapubic  and  inguinal  regions.     An  en- 
larged liver  with  a  tongue-shaped  right  lobe,  is  very  frequently  mistaken  for  a 


Fig.  232. — Patient  Lying  at  Full  Length.     First  step  in  the  examination  of  the  male. 

kidney,  as  is  an  abscess  or  a  hydatid  cyst  of  that  organ,  as  well  as  enlarged  gall- 
bladder. There  is  also  a  variety  of  enlarged  spleen,  with  a  well-rounded  lower 
border,  that  we  should  guard  against,  as  it  resembles  clearly  a  kidney,  as 
do  also  abdominal  granuloma,  enlarged  postperitoneal  glands  and  tumors  formed 
in  tubercular  peritonitis. 

In  urology,  however,  the  palpation  of  the  kidneys  is  the  most  important.  If 
they  are  normal,  they  cannot  be  felt  and  the  examination  is  not  accompanied 
by  any  pain  or  tenderness.  If  some  surgical  trouble  is  present,  they  can  gener- 
ally be  outlined  and  may  be  tender  on  pressure.  Tenderness  is  often  not  present 
even  in  kidneys  that  are  badly  diseased. 

A  counterbalance  table,  which  is  used  for  all  our  examinations,  gives  the 
patient  every  position,  from  a  lying  to  a  sitting  posture.  It  is  well  to  examine 
the  kidneys  first  while  the  patient  is  lying  flat,  with  the  legs  extended  (Fig.  233), 
and  then  with  the  knees  flexed ;  after  this,  the  back  of  the  table  is  gradually 
raised  until  the  patient  is  in  a  sitting  posture  (Fig.  23-i).    During  these  move- 


310 


EXAMINATION    OF   PATIENTS 


Fig.  233. — Examination  of  the  Kidneys,  the  Patient  Lying  Flat. 


Fig.  234. — Examination  of  the  Kidneys,  the  Patient  in  the  Sitting  Posture, 


EXAMINATION   OF  THE   ABDOMEN 


311 


merits,  the  exaniiii(>r  should  stand  on  the  side  of  tlie  patient  adjacent  to  the  kid- 
ney he  is  examining.  If  on  the  right  side,  he  should  have  his  right  hand  in 
front  on  the  onter  side  of  the  rectus  muscle  and  the  left  hand  on  the  back  below 
the  twelfth  rib.  The  position  of  the  examiner  and  his  hands  should  be  exactly 
reversed  in  examining  the  other  side.  If  the  examination  in  the  doi'su]  ])osition 
is  not  satisfactory,  the  patient  is  placed  on  the  healthy  side  with  the  knees 
slightly  flexed,  thus  allowing  the  organs  to  fall  toward  the  healthy  side  (Fig. 
235).     The  object  of  bimanual  palpation  is  to  feel  the  kidneys  between  the 


Fig.  235. — Examining  the  Kidney,  with  the  Patient  Lying  on  the  Healthy  Side. 

fingers  of  the  two  hands.  Therefore,  the  patient  should  be  instructed  to  breathe 
deeply,  thus  increasing  the  extent  of  the  renal  excursion.  With  every  expira- 
tion, the  fingers  are  pressed  more  deeply  in  until  the  kidney  region  is  reached. 
The  examiner  must  not  press  hard  when  examining  for  a  movable  kidney,  as 
it  will  slip  away  without  his  being  able  to  detect  it.  If  the  kidney  is  enlarged,  it 
should  be  ballotted  between  the  hands,  as  in  this  way  its  size,  sbape  and  con- 
sistence can  be  better  determined.  Sometimes  it  is  advisable  to  have  the  patient 
stand  during  examination. 

In  my  experience,  the  variety  of  kidneys  that  we  are  more  often  called  on 
to  treat  are  the  movable,  the  tuberculous,  the  calculous  and  the  so-called  surgical, 
pyelo-nephritis  following  cystitis.  In  these  cases,  the  organ  is  often  tender 
and  increased  in  size.  In  marked  cases  of  hydronephrosis,  pyonephrosis  and  cys- 
tic kidney,  the  mapping  out  of  the  organ  is  even  easier. 

In  the  loiver  zone  of  fJie  abdomen,  we  may  encounter  tumors,  appendicular 
or  intestinal  fecal  accumulations,  an  enlarged  bladder,  with  residual  urine,  and,' 
in  women,  a  gravid  uterus,  tumors  of  the  uterus  and  adnexa,  exudations  and 
abscesses  due  to  diseases  of  the  tubes,  periurethral  and  extraperitoneal  suppu- 
ration. 


312  EXAMINATION   OF   PATIENTS 

Examination  of  the  External  Genitals. — .Mai^e  Genitals. — I  notice  fir.st 
the  size  and  shape  of  the  organs,  whether  they  are  well  fonned  or  misshapen 
(epispadias,  hypospadias,  etc.).  The  condition  of  the  prepuce,  the  presence  or 
absence  of  snch  lesions  as  nodules  or  ulcerations,  verruca',  abscesses,  lymphan- 
gitis are  noted. 

The  meatus  is  next  inspecteil,  it  being  noted  Avhether  it  is  large  or  small, 
normal  or  distorted.  An  induration  at  the  meatus,  with  the  lips  pressed  together, 
may  indicate  the  presence  of  an  initial  lesion  of  syphilis,  or  if  ulceration  is  pres- 
ent, a  chancroid  infection  may  be  suspected.  The  presence  of  urethral  discharge 
is  also  noted  at  this  inspection  and  a  smear  should  be  taken  for  microscopic 
examination.  This  is  done  by  sterilizing  a  iDlatinum  wire  loop  by  heating  it  red 
hot  over  an  alcohol  lamp,  cooling  the  loop  and  taking  a  drop  of  the  discharge 
from  the  meatus  upon  the  loop.  The  discharge  is  quickly  smeared  very  thin 
upon  a  clean  glass  slide,  bearing  a  label  with  the  patient's  name  or  munber. 

In  each  of  the  examining  rooms,  a  compact  equipment  is  provided  for  taking 
smears,  etc.  Slides  are  kept  in  a  wide-mouthed  bottle.  A  glass  rod  with  a 
platinum  loop  and  an  alcohol  lamp  are  also  on  hand  on  each  table.  The  loo]5s 
are  used  for  obtaining  urethral,  cervical,  vaginal  or  other  discharges  which  are 
smeared  on  the  slides  in  a  thin  layer.  The  platinum  loop  is  heated  to  a  red  glow 
before  and  after  taking  each  smear. 

If  the  discharge  is  very  scanty,  it  is  sometimes  possible  to  obtain  a  sufficient 
amount  by  milking  the  urethra  from  behind  forward  and  exj^ressing  its  contents 
into  the  fossa  navicularis,  where  it  can  be  taken  up  with  a  loop. 

Caution  must  be  observed  in  drawing  hasty  conclusions  as  to  urethral  inflam- 
mations in  the  presence  of  a  discharge,  as  many  cases  of  persistent  urethral  dis- 
charge are  due  to  the  presence  of  an  initial  lesion  or  other  infection  which  we  do 
not  yet  understand. 

The  urethra  is  further  examined  by  external  palpation  along  its  entire  length, 
the  presence  of  nodules,  indurations,  swellings,  abscess  formations  or  fistulne 
being  noted.  The  testes  are  next  palpated,  tenderness,  enlargements,  nodules, 
etc.,  of  testes,  epididymis  or  cord  being  noted,  indicating  the  existence  of  inflam- 
mation, tuberculosis  or  syphilitic  processes,  the  beginning  of  malignant  tumors, 
etc.,  as  well  as  the  presence  of  hydrocele,  varicocele  or  hernia. 

Female  Genitals. — In  order  to  examine  the  external  female  genitals,  the 
patient  must  be  brought  down  to  the  edge  of  the  table  in  the  gynecological  posi- 
tion (Fig.  236)  and  the  same  conditions  must  be  looked  for  as  in  the  male, 
viz. :  deformities,  swellings,  nodules,  ulcerations,  verrucse,  abscesses  and  lym- 
phangitis. The  glands  of  Bartholini  are  pressed  upon  to  see  if  there  is  a 
purulent  discharge  from  the  ducts.  The  presence  of  vaginal  discharge  is  noted 
and  a  smear  taken  if  it  is  present.  The  labia  are  then  separated  and  the  vesti- 
bule sponged  with  a  bichlorid  solution,  1 :  5,000.  The  forefinger  of  the  left  hand 
is  then  inserted  into  the  vagina  against  the  urethra  at  the  point  where  it  leaves 


EXAMINATION   OF   THE  MALE  PATIENT   STANDING 


313 


Fig.  236. — Position  for  Examining  the  Female 
Genitals  and  Urethra. 


the  bladder  aud  is  then  drawn  down  toward  the  meatus,  making  pressure  all 

along  the  canal.     In  case  discharge  is  seen,  it  is  taken  on  a  slide  if  there  is 

sufficient  quantity,  otherwise  a 

})latinum   loop   is  inserted  into 

the  meatus  and  an  effort  made 

to     secure     a     specimen      (see 

chapter  on  Discliargcs). 

XoTE. — So  far  the  exam- 
inations have  been  on  the 
table  in  both  sexes ;  but  they 
must  now  be  considered  sepa- 
rately on  account  of  the  dif- 
ference in  the  anatomy  of  the 
sexes.  I  will,  therefore,  first 
give  the  procedure  in  the  case 
of  the  male  and  then  take  up 
that  of  the  female. 

Examination  of  the  Male  Patient  Standing. — The  First  Urine. — The 
patient  is  next  directed  to  stand  up  and  is  handed  a  glass  cylinder  by  the  exam- 
iner. Into  this  he  is  instructed  to  pass  a  portion  of  his  urine  (Fig.  237).  Fre- 
quently in  the  embarrass- 
ment caused  by  the  exam- 
ination, or  for  some  other 
psychical  reason,  the  patient 
is  unable  to  urinate  prompt- 
ly at  this  moment.  In  order 
to  aid  him  as  much  as  pos- 
sible, two  measures  may  be 
adopted.  The  first  is  to  leave 
him  to  himself,  the  second  is 
to  allow  a  thin  stream  of 
water  to  trickle  from  a  fau- 
cet in  the  room  in  which  he  is 
being  examined.  This  acts 
on  the  motor  centers  of  the 
bladder  through  the  mental 
impression  which  suggests 
urination  through  the  very 
sound  of  the  stream  of  water. 
The  size,  shape  and  force  of  the  stream  is  noted,  if  possible,  when  the  patient 
passes  water.  A  healthy  man  with  a  normal  urethra  and  bladder  passes  a  fairly 
large  stream,  projecting  from  his  body  at  a  distance  of  from  three  to  five  feet 


Fig.  237. — Male  Patient  Urinating  in  a  Glass  Cylinder. 


314 


EXAMINATIOX    OF   PATIENTS 


when  standing  up.  A  man  with  a  small  meatus  has  a  smaller,  but  usually  a 
forcible  stream.  A  sudden  in1ci'ru])tiun  of  the  stream  which  begins  normally, 
often  points  to  the  presence  of  stone  in  the  bladder.  On  the  other  hand,  a  stream 
which  slowly  becomes  smaller  and  less  forcible  points  to  either  some  obstruction, 
siich  as  stricture,  prostatic  enlargement,  acute  congestion  of  the  prostate,  acute 
or  chronic  prostatitis,  or  to  a  lack  of  tone  of  the  bladder.  Further  details  as  to 
the  character  of  the  stream  will  be  found  in  the  chapter  discussing  the  subject  of 
urination. 

After  the  first  urine  is  passed,  it  is  held  up  to  the  light  to  see  if  it  is  light 
or  dark,  clear  or  turbid,  and  examined  for  pus,  shreds  and  mucus.  The  signifi- 
cance of  these  various  elements  is  considered  more  in  detail  under  the  subjects 
of  urine  and  discharges. 

Second  Ukine. — The  patient  is  then  handed  a  second  glass  cylinder,  of  the 
same  size  and  shape  as  the  first,  and  is  asked  to  void  a  second  portion  of  his  urine, 
but  is  warned  not  to  pass  the  entire  contents  of  his  bladder.  The  second  urine 
is  inspected  in  the  same  way  as  the  first,  any  cloudiness,  shreds  or  a  dej)Osit  of 
pus,  etc.,  being  noted. 

Pkostate  axd  Vesicles. — The  patient  is  then  told  to  bend  forward.  lie 
leans  over,  resting  on  his  hands  placed  on  a  table.     The  body  is  at  an  angle  of 


A 


A,  finger  cot  unrolled. 

B,  finger  cot  rolled  up. 


C  D 

Fig.  238. — The  Finger  Cot. 

C,  piece  of  gauze  to  wind  about  the  finger. 

D,  the  hand  with  the  finger  cot  on  the  forefinger 

and  the  piece  of  gauze  wound  about  it. 


135  degrees  to  the  perpendicular.  The  examiner  places  a  finger  cot  on  his  fin- 
ger (see  Fig.  238)  and  winds  a  piece  of  gauze  about  the  base  of  it  to  keep 
his  finger  clean.     He  then  sits  behind  him  and  inserts  the  forefinger  of  the  right 


EXAMINATION   OF   THE    jMALE   PATIENT   STANDING  315 

luuid  into  the  rectiiiii  and  cxaiiiincs  tlic  ])r()sratc.  lie  tlieii  presses  the  fore  and 
middle  ting-er  of  the  left  hand  into  the  groin  of  the  patient,  thus  pushing  the 
vesicle  down  against  the  examining  finger  (Fig.  230).  It  is  strange  that  much 
experience  is  necessary  to  examine  well  the  internal  genitals,  but  snch  is  the 
case.     The  examiner  notes  the  outline  of  these  organs,  the  presence  <.f  nodules, 


Fig.  239. — Examination  by  Rectum.  The  patient  leans  over  the  table  and  the  examiner  inserts  his 
right  forefinger  into  the  rectum,  presses  the  fingers  of  the  left  hand  into  the  groin,  and  palpates 
the  vesicles  bimanually. 

depressions,  as  well  as  the  general  consistence  and  tenderness  of  the  parts.  A 
hard  prostate,  either  normal  or  small  in  size,  may  give  rise  to  frequency  of  uri- 
nation from  a  cause  which  cannot  as  yet  be  determined,  though  probably  owing 
to  pressure  exerted  by  a  very  tense  external  capsule.  A  prostate  which  is  soft 
and  boggy  indicates  a  chronic  prostatitis,  in  which  case  the  gland  has  become 
atonic.  Modules  in  the  prostate  show  local  areas  of  follicular  inflammation  or 
simple  chronic  or  tuberculous  prostatitis.  An  intensely  tender,  hot,  swollen,  en- 
larged turgid  gland,  with  one  or  both  lobes  involved,  is  characteristic  of  acute 
prostatitis.  An  enlargement  of  the  gland  in  young  men  without  the  acute  signs 
just  mentioned,  but  usually  with  nodular  swellings,  points  to  a  tuberculous  proc- 
ess.    In  elderh^  men,  an  cnhirgement  usually  indicates  prostatic  hypertrophy,  or 


316 


EXAMINATION    OF    PATIENTS 


else  malignaut  growth.  A  shrunken  prostate,  with  an  irregular  outline  and  with 
depressions  or  softened  areas,  shows  the  seat  of  former  abscesses  which  have 
destroyed  a  part  of  the  prostatic  tissue. 

Engorged,  thick,  tender  vesicles  point  to  an  acute  vesiculitis.  Moderately 
distended  vesicles  with  the  walls  not  so  thick,  although  tender,  point  to  a  sub- 
acute process,  or  to  congestion,  ^vith  some  retention  of  vesicular  secretion.  When 
the  vesicles  are  tender  and  cannot  be  outlined,  they  are  probably  simply  con- 
gested. 

In  the  chronic  condition,  vesicles  have  thickened,  atoidc  walls  perhajis  full 
of  vesicular  secretion  and  inflammatory  products,  due  to  a  subacute  inflamma- 
tion probably  associated  with  a  thickening  of  the  neck  of  the  vesicle  or  pressure 
on  the  ejaculatory  duct  by  the  prostate.  The  vesicles  often  have  a  pasty  feeling 
and  dent  in  when  pressed  with  the  flnger  as  if  full  of  cheesy  matter.  Xodular, 
irregular  vesicles  are  the  result  of  chronic  inflammation,  in  consequence  of  which 
there  has  been  a  retention  of  vesicular  secretion.  Localized  thickenings  in  cer- 
tain parts  of  the  vesicles  are  due  to  stricture  or  scar  tissue ;  they  may  also  be 
due  to  tuberculosis.     Small  vesicles,  hard  and  irregular,  are  the  result  of  chronic 

inflammation  and  partial  destruction.  If  this 
destructive  process  goes  on  still  further,  they 
will  probably  atrophy  until  they  cannot  be  felt. 
Third  Urine. — During  the  examination  of 
the  prostate  and  vesicles,  the  organs  are  gently 
massaged  with  the  finger  (Fig.  240).  When 
the  finger  is  withdrawn,  the  patient  is  instructed 
to  void  the  remainder  of  his  urine  in  a  third 
cylinder.  This  third  urine  represents  the  con- 
tents of  the  bladder  plus  the  material  massaged 
from  the  prostate  and  the  vesicles  into  the  pos- 
terior urethra.  W^e  are  now  ready,  with  the 
three  cylinders  of  urine  before  us,  to  compare 
them  and  to  draw  such  conclusions  as  may  be 
warranted  from  their  appearance. 

The  first  urine  contains  the  -washings  of  the 
urethra  plus  any  elements  from  the  kidney,  ure- 
ter and  bladder  that  may  be  present.  The  sec- 
ond urine  represents  that  from  the  bladder, 
ureter  and  the  kidney  alone,  as  all  the  products  of 
inflammation  that  were  present  in  the  urethra 
were  washed  out  by  the  first  urine.  The  third 
urine,  as  we  have  seen,  contains,  in  addition  to  the  second  urine,  the  elements 
massaged  from  the  prostate  and  vesicles. 

The  urines  are  then  sent  to  the  laboratory  for  examination. 


Fig.  240. — Massage  of  the  Pros- 
tate. The  arrow  shows  the  di- 
rection in  which  the  tip  of  the 
forefinger  moves  in  this  maneu- 
ver. 


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EXAMINATION    OF    THE   URINES 


317 


Examination  of  the  Urines. — The  followiiii^'  table  represents  tlie  chief  pos- 
sil)ilities  encountered  in  examining  the  three  urines  at  the  time  the  patient  passes 
them  and  indicates  in  each  case  the  significance  of  the  findings. 


First  Urine. 


(1)  Clear. 

(2)  Clear. 


Second  Urine. 


Third  Urine. 
{After  massaye  of  the  prostate.) 


Clear. 
Clear. 

Clear. 


(3)  Clear  (small  float- 

ing mass,  clear) 

(4)  Clear,  with  heavy! Clear. 

shreds. 

(5)  Turbid,    heavy'Clear. 

shreds.  [ 

(6)  Clear,    heavyClear. 

shreds.  | 

(7)  Turbid,    heavy;Clear. 

shreds.  j 

(8)  Turbid,  no  shreds.  iTurbid 


Clear. 

Cloudy,  with  debris 
Opaque,  debris. 
Turbid,  no  debris. 
(9)    Turbid,    with  No  shreds  or  flocculi.  No  debris,  turbid. 


Clear. 

Slightly  opaque,  with 

debris. 
Slightly    opaque,    with 

debris. 
Clear. 


shreds 

(10)  Turbid,  shreds. 

(11)  Turbid,  slireds. 


turbid. 

Turbid,  shreds  and 

flocculi. 
Turbid,  shreds. 


No  debris,  turbid. 
Turbid,  with  debris. 


Summa.y. 
( What   they    show ;  parts  in- 
volved.) 


Normal  urine. 
Prostate. 

Prostate  and  vesicles. 

Chronic  urethritis. 

Chronic  urethritis. 

Urethra,  prostate  and 
vesicles. 

Chronic  urethritis,  pros- 
tatitis, vesiculitis. 

Pyuria,  bladder  kidney 
or  both. 

Urethra,  bladder,  kid- 
ney or  both  or  phos- 
phaturia. 

Urethra,  bladder  or  kid- 
ney. 

Urethra,  bladder  pos- 
sible, kidney  possible, 
prostate  or  vesicles, 
phosphaturia. 


This  table  is  quite  difficult  to  understand.  We  should  first  eliminate  phos- 
phaturia. If  the  urine  is  turbid,  therefore,  a  small  amount  is  poured  into  a 
test-tube  and  a  little  acetic  acid  is  added.  If  the  turbidity  is  due  to  phosphates, 
it  will  at  once  disappear.  This  test  should  be  performed  whenever  both  the  first 
and  second  urines  are  opaque. 

If  the  urine  does  not  become  clear  with  the  acid,  another  portion  of  it  is 
poured  into  a  test-tube  and  is  shaken  with  some  liquor  potassa?.  If  the  turbidity 
is  due  to  pus,  a  thick  coagulum  will  form  and  sink  to  the  bottom,  leaving  a 
clearer  upper  portion. 

In  order  to  differentiate  between  inflammatory  ])ro(lucts  massaged  from 
the  vesicles  and  those  obtained  in  the  third  urine  from  the  prostate,  we  should 
note  the  following  points : — 

Urethra : 

Urethral  shreds. 

Prostate : 

(1)  Plugs  or  comma-shaped  bodies  are  from  the  mouths  of  the  ducts. 

(2)  White  thick  masses  in  turbid  urine,  coming  from  the  dilated  and  chron- 
ically inflamed  ducts. 

Vesicles  : 

(1)  8ago  hodics  consist  of  the  coagulated  secretion  of  the  vesicles  that  have 
become  molded  in  the  convolutions  of  the  vesicles. 


318  EXAMINATION   OF   PATIENTS 

(2)  Sugar  granules^  amber  C(jlorc(l  (or  colorless)  bodies  resoin])liiig  sn<rar 
granules.  Of  the  same  material  as  the  sago  bodies  but  firmer  in  consistence, 
not  so  abundant  and  smaller. 

(3)  Spermatozoa^  alive  or  dead,  whole  or  in  broken  pieces. 

(4)  Plugs  of  2JUS  coagula  mixed  with  epithelia  from  the  vesicles. 

(5)  Meynhraiious  fakes  that  resemble  small  pieces  of  skin  oi-  mcinbi-aiie 
looking  like  egg  membrane,  white  in  color,  consisting  of  a  dei^osit  on  the  walls 
of  the  vesicles,  of  sufficient  thickness  to  come  away  in  jiieces. 

(6)  Snoiuflahes^  light  particles  resembling  snowflakes,  not  as  heavy  as  the 
larger  flakes.  These  are  recent  deposits  which  have  not  become  formed  as  a 
membrane. 

The  different  formations  from  the  vesicles  are  probably  composed  of  the 
same  material,  principally  globulin,  and  differ  mainly  in  the  length  of  time 
that  they  have  been  secreted  and  deposited  on  the  mucous  membrane  of  their 
walls ;  in  the  quantity  in  which  they  have  been  secreted ;  whether  suddenly  in 
large  amount,  or  slowly  in  small  quantity;  and  whether  the  secretion  is  ]nire 
or  mixed  with  large  amounts  of  epithelia,  spermatozoa,  pus  and  other  products 
of  inflammatory  exudate.  After  massage  and  after  being  allowed  to  settle  in 
a  glass  alone  or  mixed  with  prostatic  fluid,  or  urine,  they  lose  the  characteristic 
shapes  that  they  have  on  escaping  and  become  a  blended  gelatinous  deposit.  At 
times,  casts  of  the  vesicles  are  passed  after  massage,  an  inch  or  more  in  length, 
from  one  or  both  vesicles.  The  casts  may  be  of  sufficient  size  to  block  the 
urinary  stream.  It  is  hard  to  understand  how  masses  of  this  size  can  es- 
cape from  the  ejaculatory  ducts,  for  I  have  seen  them  of  the  size  of  a  leech, 
so  that  for  a  moment  the  patient's  urine  would  stop  and  the  mass  would 
suddenly  be  expelled  with  force,  followed  at  once  by  the  remainder  of  the 
urine. 

Urethral  Examination  {the  Patient  on  the  Table  at  Full  Length'). — In  ex- 
amining the  urethra,  I  stand  on  the  patient's  right.  The  urethra  is  first  palpated 
by  holding  the  ]Denis  in  one  hand  and  palpating  the  outside  of  the  canal  with 
the  thumb  and  forefinger  of  the  other.  In  this  way,  a  follicular  induration  or 
inflammation,  associated  with  a  urethral  follicle,  a  periurethral  abscess,  scar 
tissue,  a  foreign  body  or  stone  in  the  canal,  may  be  detected. 

The  canal,  unless  it  is  acutely  inflamed,  is  then  examined  with  instruments : 
bougies  a  boule,  sounds,  catheter  or  filiform.  I  first  sponge  the  meatus  with 
a  cotton  ball  soaked  in  bichlorid  1 :  1,000,  then  take  in  my  right  hand  a  bougie 
a  boule  (Fig.  241)  about  the  size  that  I  think  will  just  enter  the  meatus.  I  dip 
its  end  into  a  bottle  of  glycerin  and  steady  the  organ  with  the  fingers  of  the  left 
hand  placed  on  either  side  of  the  corona.  I  then  insert  the  instrument  through 
the  meatus.  In  case  it  will  not  enter,  I  take  up  smaller  ones  until  I  find  one  that 
will  pass  in  easily.  If  the  first  instrument  passes  easily,  I  go  up  the  scale  until 
I  find  the  largest  that  will  c'o  to  the  bulb.     I  reffister  the  number  of  the  instru- 


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URETHEAL   EXAMINATION 


319 


mont  that  passes  the  narrowest  point  oi-  ])oiiits  of  the  canal  and  the  distance  of 
these  narrowings  from  the  meatus. 

I  then  take  a  sound  corresponding  in  size  to  the  bougie  a  boule,  with  a  short 
heak,  and  pass  it  into  the  urethra  following  the  upper  wall.  If  this  glides 
easily  into  the  1  (ladder,  I  register  "  Ure- 
tlira  No.  —  at  meatus  "  or  whatever  dis- 
tance from  it  the  narrowing  may  be  and  add 
"  Sound  No.  —  passes  easily  into  bladder." 

In  case  the  smallest  bougie  a  boule  (No, 
6  French)  does  not  pass  to  the  bulb  or  that 
a  sound  of  that  size  does  not  pass  through 
the  remainder  of  the  urethra,  the  locality  of 
the  impediment  must  be  registered.  It  will 
then  be  necessary  to  pass  a  smaller  instru- 
ment^— a  filiform  bougie  No.  1  or  No.  2 
(Fig.  242). 

If  the  filiform  passes  the  point  of  nar- 
rowing at  which  the  larger  instrument 
failed  to  pass,  it  will  be  spoken  of  as  a  fili- 
form stricture.  In  case  the  filiform  fails  to 
pass,  the  impediment  will  be  spoken  of  as 
an  impassable  stricture. 

When  the  patient  passes  a  fairly  good 
stream  and  yet  a  filiform  cannot  be  passed, 
the  location  of  the  impediment  must  be  con- 
sidered. If  it  is  in  the  deep  or  bulbous 
portion  of  the  urethra,  the  instrument  may 
have  entered  a  pocket,  in  which  case,  by  in- 
serting a  filiform  with  a  spiral  end  like  a 
No.  2  and  rotating  it  slowly  during  its  in- 
troduction, the  end  may  pass  along  the  ure- 
thra by  the  pocket  without  sliding  into  it.  In 
case  the  impediment  is  in  the  posterior  ure- 
thra and  the  remainder  of  the  canal  is  larger,  it  is  probably  not  a  stricture,  but 
an  enlarged  or  deformed  prostate.     If  the  patient  is  an  did  man,  the  condition  is 


Fig.  241. — The  Bougie  a  Boule  Mov- 
ing DOWN  THE  Urethra  through  a 
Strictured  Area. 


No.  1  ' 
No.  2 


Nu.  3   ^ 


No.  1,  straight. 


Fig.  242. — Filiform  Bougies. 
No.  2,  with  a  spiral  end.  No.  3,  with  a  bend  near  the  end. 


320 


EXAMINATION   OF   PATIENTS 


probably  hypcrtrojiliy  and  a  small  eoiidc'  catlietor  would  pass  over  the  impedi- 
iiieiit  and  into  the  bladder  :  wliile  if  tbe  patient  is  a  ycnmg  man  who  has  had  a  bad 
attack  of  jirostatitis,  the  im})ediment  would  probably  be  the  result  of  a  prostatic 
abscess,  a  cavity  or  an  irregnlarity  which  j)revents  the  entrance  of  the  instru- 
ment. As  these  conditions  are  nsnally  in  the  floor  of  the  nrethra,  a  coude  cathe- 
ter which  tends  to  hug  the  roof  of  the  canal  may  pass  throngh  into  the  bladder. 
At  times  the  anterior  urethra  is  of  large  size  with  smooth  walls  and  the  sound 
goes  up  against  an  impediment  at  the  bulb  or  at  the  neck  of  the  bladder.  In 
such  a  case,  we  must  think  of  a  spasmodic  stricture  of  the  cut-off  muscle,  de- 
pendent on  an  inflamed  condition  of  the  prostate  or  prostatic  urethra  in  the  first 
instance,  whereas,  in  the  second  instance,  of  spasm  of  the  vesical  sphincter  due 
to  an  inflammation  of  the  bladder  neck.  In  such  cases,  an  instillation  of  cocain 
solution,  or  nitrous-oxid  anesthesia,  may  be  used  in  the  examination.  If  noth- 
ing can  be  passed  through  a  urethra  under  anesthesia  and  the  patient  is  able  to 
pass  some  urine  although  he  has  symptoms  of  urinary  obstruction,  no  further  ex- 
amination can  be  made  in  his  case  excepting  of  his  urine,  and  he  should  be  sent 
to  the  hospital  or  home  for  further  observation.  A  few  days'  rest  in  bed  under  a 
treatment  of  hot  sitz  baths,  diluents,  a  liquid  diet  and  a  large  amount  of  water, 
will  probably  so  change  the  character  of  the  imj)ediment  as  to  allow  some  instru- 
ment to  pass.  Such  cases  rej)resent,  however,  a  minority  of  those  which  come  to 
our  office.  The  majority  of  the  cases  have  urethras  of  a  fair  size,  that  is,  over 
15  French. 


Fig.  243. — The  Examiner  Looking  through  the  Urethroscope  at  the  Urethral  Bulb. 


If  the  patient  has  but  a  slight  chronic  urethral  discharge  and  the  canal  is 
over  20  French  in  size,  the  urethroscope  is  frequently  used  at  the  first  visit, 
especially  with  patients  from  out  of  town  or  those  who  are  accompanied  by  their 
physicians. 


COMPLETION    OF    THE    EXAMINATION    IN    WOMEN 


321 


1  n  this  case,  tlu;  ui'C'tlirosco])e  ( I^'ii!,'.  24-'5  )  is  dippcil  into  <ilyc('riii  aiul  iiitro- 
diiced  in  tlie  same  way  as  a  bougie  a  bonle.  The  iiiandi'iii  is  then  witlidrawn 
and  a  cotton  swab  is  inserted  to  dry  the  interior  of  the  tube  and  the  urethra. 
A  light  carrier  is  then  introduced  and  connected  with  the  rheostat  on  the  wall  at 
the  side  of  the  table.  By  this  means,  polypi,  ulcers,  erosions  and  granular 
patches  can  be  seen  and  noted  on  the  history  card.  This  particular  instrument  is, 
I  believe,  better  than  any  of  the  other  straight  tubes  for  examining  the  poste- 
rior urethra,  on  account  of  the  curve  near  its  end,  and  it  is  tilted  down  and 
pushed  gently  in,  hugging  the  upper  wall  of  the  urethra.  If  it  is  pushed  in  too 
far,  it  will  enter  the  bladder  and  a  gush  of  urine  will  follow,  in  which  case,  it 
should  be  pulled  down  below 
the  sphincter,  wdien  the  flow 
will  stop  and  the  posterior 
urethra  can  be  examined. 

Completion  of  the  Ex- 
amination in  Women.  — 
The  first  part  of  the  exami- 
nation in  women,  including 
the  abdomen  and  external 
genitals,  was  concluded  in 
the  early  part  of  this  chap- 
ter. It  now  remains  to 
obtain  speciinens  of  the 
urine  and  to  examine  the 
internal  genitals.  The  pa- 
tient is  asked  to  step  be- 
hind a  screen  and  to  seat 
herself  on  a  commode 
and  void  urine  (Fig.  244). 
The  bucket  of  this  com- 
mode has  been  removed 
and  a  large  funnel  put  in 
its  place,  below  which  a 
glass  is  placed,  in  such  a 
position  that,  when  the  pa- 
tient voids  the  first  urine,  it  enters  the  funnel  and  runs  through  it  into  the  cylin- 
der below.  The  nurse  then  removes  it  through  a  door  in  the  side  of  the  connnode, 
places  a  second  glass  under  the  funnel  and  then  asks  the  patient  to  jiass  the  re- 
mainder of  her  urine.  The  imrse  then  carries  the  specimens  to  the  examiner, 
who  inspects  the  two  specimens  before  sending  them  to  the  laboratory.  If  the 
first  specimen  is  clear  and  there  are  no  shreds,  it  will  show  that  the  urethra, 
bladder  ar.d  kidneys  are  free  from  any  marked  suppuration.     If  the  first  is  clear 


Fig.  244. — Female  Patient  Sitting  on  a  Commode.  A  glass 
funnel  is  beneath  the  seat.  Below  the  funnel  is  the  glass 
cylinder. 


322  EXAMINATION   OF  PATIENTS 

with  shreds  and  the  second  is  clear  without  shreds,  it  will  show  a  mild  urethritis. 
If  the  first  is  turbid  with  shreds  and  the  second  is  clear,  it  will  show  a  more 
acute  type  of  urethritis  with  no  other  involvement.  If  the  first  and  second  urine 
are  both  turbid,  it  will  show  pyuria  or  phosphaturia  which  can  be  determined  by 
the  rapid  clinical  tests  of  the  examining  room.  If  it  is  pyuria,  the  source  of 
the  pus  will  be  determined  by  the  laboratory  examination. 

The  female  patient  is  then  returned  to  the  table,  where  the  examination  of 
her  internal  genitals  is  continued.  (See  Fig.  236.)  Her  perineum  is  examined 
for  lacerations  and  any  cystocele  or  rectocele  noted.  The  uterus  is  palpated  to 
discover  any  laceration  of  the  cervix,  tenderness,  induration,  enlargement  or  dis- 
placement of  the  organ,  free  mobility  or  fixation  or  the  presence  of  a  tumor.  The 
ovaries  and  tubes  are  then  examined  for  tenderness,  enlargement  or  displacement. 
Exudates  of  a  varying  degree,  depending  upon  metritis  or  salpingitis,  are  of  the 
greatest  importance.  The  speculum  is  then  introduced  and  the  cervix  inspected 
for  lacerations,  ulcerations,  or  the  presence  of  discharge  or  hemorrhage.  Uterine 
displacements  or  prolapse,  fibroma  or  carcinoma,  or  adhesions  due  to  inflamma- 
tion of  the  adnexa,  are  all  important  on  account  of  interfering  with  the  functions 
of  the  bladder  as  well  as  predisposing  to  cystitis. 

The  routine  examination  of  the  urethra  and  bladder  is  the  same  in  women 
as  in  men,  although,  in  the  former,  the  passing  of  instruments  is  much  easier 
owing  to  the  absence  of  the  prostate  gland.  Urethral  lesions  are  not  so  com- 
mon in  women  as  in  men,  but,  although  strictures  are  not  usually  looked  for, 
they  are  more  frequently  present  than  is  generally  supposed. 

Diseases  of  the  bladder  are  not  so  common  in  women,  the  most  frequent  being 
tuberculosis.  Female  bladders,  however,  are  much  aff'ected  by'  the  condition  of 
the  surrounding  organs  and  often  to  a  sufficient  degree  to  give  rise  to  the  great- 
est suffering  and  inconvenience. 

Records. — With  each  history  chart,  is  filed  the  diagram  of  the  urinary  tract 
represented  in  Figs.  1  and  2  in  the  chapter  on  Anatomy,  on  which  any  lesions 
found  are  marked  so  as  to  be  visible  at  a  mere  glance.  These  diagrams  were 
made  from  a  dissection,  made  at  the  ISTew  York  Post-Graduate  School  (Guiteras, 
Philadelphia  Medical  Journal,  June  2,  1900). 

The  examination  having  been  completed  and  a  tentative  diagnosis  made, 
the  line  of  treatment  indicated  is  recorded  on  the  back  of  the  card  and  changes 
made  on  subsequent  visits  are  appended.  If  an  operation  is  performed,  it  is 
described  and  a  pathological  report  of  anything  removed  is  added. 

The  report  of  the  urinary  analysis  made  from  a  twenty-four  hours'  specimen 
is  also  attached  to  the  history  card  represented  in  the  chapter  on  The  Urine. 

The  entire  documentary  record  of  the  case,  including  copies  of  the  corre- 
spondence with  the  patient  or  with  the  family  or  physician,  is  filed  in  an  envel- 
ope in  a  vertical  filing  case,  in  alphabetical  order.  In  this  way  anything  per- 
taining to  each  case  is  instantly  available  for  investigation. 


CHAPTER    XVI 

UROLOGICAL  THERAPEUTICS 

In  the  treatment  of  patients,  the  first  thing  that  is  expected  of  a  physician  is 
a  prescription  for  medicine ;  in  fact,  it  seems  to  be  the  general  idea  that  every 
symptom  indicates  a  disease  that  should  call  for  a  specific  drug.  It  is  true  that 
there  are  certain  drugs  that  are  specific ;  but  in  urology  proper,  no  drug  has  yet 
been  found  that  can  be  considered  as  such.  It  seems,  in  this  branch  more  than 
any  other,  that  it  is  important  to  keep  the  patient  in  the  best  physical  condition 
by  regulating  the  diet,  digestion,  bowels  and  the  amount  and  variety  of  exercise 
in  those  v^ho  are  up  and  about;  to  protect  the  surface  of  the  body  by  suitable 
clothing;  and  to  keep  the  function  of  the  skin  as  perfect  as  possible.  Drugs 
should  be  prescribed  to  assist  nature  when  functions  of  certain  parts  are  at 
fault ;  to  reduce  congestion  and  inflammation  when  necessary ;  to  stimulate 
when  the  tissues  are  weak ;  and  to  counteract  and  destroy  infections. 

DIET 

Diet  is  one  of  the  most  important  factors  in  treatment.  Many  people  suffer 
through  errors  of  diet.  A  visit  to  health  resorts,  where  people  are  cured  simply 
by  leading  a  regular  life,  resting  or  exercising,  according  to  the  case,  following 
a  simple  diet  and  drinking  a  certain  water,  or  bathing — without  taking  a  drug 
— is  a  strong  argument  in  favor  of  the  fact  that  drugs  are  not  always  necessary. 

Simple  Diet. — Simple  food  that  is  easily  digested  and  assimilated,  and  does 
not  give  rise  to  irritating  by-products,  is  then  a  most  important  remedy  in  the 
treatment  of  disease  and  especially  in  urology.  A  milk  diet  alone,  or  combined 
with  some  mild  alkaline  water,  is  the  simplest  of  all  diets.  Such  a  one  should  be 
prescribed  in  acute  nephritis,  the  severest  of  all  diseases  of  the  urinary  tract. 
It  should  also  be,  ordered  in  chronic  nephritis,  when  uremia  is  threatened  or 
present.  It  can  be  prescribed  to  patients  suffering  from  acute  parenchymatous 
prostatitis  and  in  prostatic  hypertrophy,  or  in  stricture  cases,  when  retention  is 
]U'esent,  due  to  congestion.  It  is  also  recommended  in  all  complications  due  to 
infections  of  the  urinary  tract. 

Simple  diet  for  the  patients  who  are  up  and  about  their  regular  pursuits  of 
life,  is  quite  liberal.  In  this  case,  fruit,  cereals,  bread,  eggs,  milk,  fish  and  shell- 
fish, meat,  green  vegetables,  salad  and  cheese  are  regarded  as  simple  diet.     It 

323 


324  UROLOGICAL   THERAPEUTICS 

is  only  necessary  to  eat  in  moderation  food  siiniily  prepared;  to  take  a  variety 
rather  than  too  much  of  any  one  kind;  to  see  that  the  food  is  prepared  in  a 
simple  and  digestible  manner;  to  avoid  stimulants,  condiments  and  rich  dishes. 

I  think  that  most  of  ns  wonld  be  in  better  condition  if  we  ate  nothing  fried, 
nothing  sweet,  no  condiments  and  did  not  nse  alcoholics,  tea,  coffee,  or  tobacco, 
but  such  would  hardly  be  pi-acticable  in  our  present  manner  of  living. 

Fruits. — Fruits  should  be  eaten  at  the  morning  and  midday  meals,  rather 
than  at  the  evening  repast.  For  breakfast,  orange,  cantaloupe,  peaches,  baked 
apple  and  grape  fruit  are  preferable ;  whereas,  for  the  midday  meal,  any  of  the 
same  varieties  can  be  used,  as  well  as  apples,  pears  or  plums.  Xo  sugar  should 
be  eaten  on  the  fruit. 

I  do  not  consider  berries  healthful,  as  they  frequently  irritate  the  intes- 
tines, especially  strawberries,  although  some  consider  this  mechanical  irritation 
good  in  case  of  constipation. 

Stewed  fruit  is  considered  healthier  than  raw,  but  is  usually  too  much 
sweetened. 

Cereals. — Cereals  are  usually  taken  at  the  morning  meal  and  eaten  gen- 
erally with  cream  and  sugar.  They  are  often  rich  in  starch  and  oils,  and  are 
made  richer  by  the  addition  of  sugar  and  cream.  Personally,  I  think  it  is  a 
mistake  to  put  cream  and  sugar  on  cereals,  and  that  it  is  better  to  use  salt 
and  milk.  I  do  not  look  upon  cereals  as  a  necessary  breakfast  food,  but  if  they 
are  to  be  partaken  of,  I  advocate  those  made  from  corn,  barley,  or  oats,  rather 
than  the  wheat  products. 

Eggs  are  the  most  nourishing  and  most  easily  digested  of  the  nitrogenous 
foods  that  can  be  taken,  and  should  be  eaten  either  soft  boiled,  poached  or 
shirred,  for  breakfast  or  lunch. 

Bread. — Bread  from  the  ordinary  loaf  is  not  advised,  unless  it  is  toasted  a 
day  or  so  after  baking,  when  it  is  quite  easily  digestible.  Thin  French  bread 
and  rolls,  with  a  large  amount  of  crust  and  a  small  amount  of  crumb,  are  more 
easily  digested.  These  can  be  heated  in  the  oven  for  a  few  moments.  Hot  bread, 
that  is,  the  bread  freshly  baked,  which  is  composed  mostly  of  the  crumb,  is  most 
indigestible.  Corn  bread  cannot  be  recommended,  as  it  usually  contains  too 
much  sweetening,  for  neither  much  shortening  nor  sweetening  is  well  tolerated. 

Coffee  and  Tea. — Coffee  and  tea  are  stimulating  in  the  morning  and  have 
a  good  effect  upon  the  heart  and  circulation.  Their  active  principle — caftein — 
is  a  powerful  stimulant  and  diuretic ;  but  it  is  a  question  whether  it  is  not 
injurious  to  stimulate  the  heart  and  blood  vessels  three  times  a  day,  as  persons 
so  frequently  do. 

I  do  not  recommend  the  use  of  tea  and  coffee.  If  taken  for  breakfast,  mild 
cafe  ail  la  it,  made  by  adding  one  tablespoon  of  freshly  ground  coffee  to  half  a 
pint  of  hot  milk  at  the  point  of  boiling,  made  in  a  French  drip  coffee  pot,  is 
sufficient.      The  hot  milk  is  usually  poured  through  twice;  no  water  need  be 


DIET  325 

used  ill  its  preparation.  Sncli  a  preparation  is  muoli  more  nourishing  than  a 
cupful  of  coffee  with  a  small  amount  of  cream.  If  taken  after  dinner,  a  small 
cup  of  black  coffee  is  sufficient. 

Fish,  Meat  and  Vegetables. — Fish,  meat,  vegetables  and  greens  should  be 
taken  at  the  midday  and  evening  meals.  For  health  and  good  digestion,  I 
think  ihat  it  is  better  to  take  a  heavier  meal  in  the  middle  of  the  day,  as  the 
lighter  meal  in  the  evening  would  be  more  easily  digested  and,  consequently, 
would  not  interfere  so  much  with  sleep.  In  city  life,  however,  especially  in 
those  who  do  active  brain  work,  the  midday  meal  should  be  lighter.  I  believe 
tiiat  two  meals  a  day  are  better  tolerated  than  three,  when  taken  one  at  10  or  11 
A.M.,  and  the  other  at  5  or  6  p.m. 

Shellfish,  as  oysters  and  clams,  are  good  for  lunch  and  dinner.  They  are 
more  easily  digested  raw,  except  the  so-called  soft  clams,  which  are  better 
steamed,  stewed  or  baked. 

Soups. — Consomme  is  good  in  a  light  diet  and  at  the  beginning  of  a  lunch 
or  dinner.  Heavier  soups  may  be  eaten  at  dinner,  but  bisque  and  creams  are 
not  recommended. 

Fisii. — Fish  should  be  eaten  broiled,  boiled  or  baked.  The  broiled  fish  is 
the  most  palatable,  but  boiled  fish  is  very  delicate  if  properly  cooked.  Fish  is 
more  easily  digested  than  meat,  especially  fish  of  the  smaller  varieties — that  is, 
weighing  less  than  four  pounds.  It  is  a  good  luncheon  food,  if  the  midday 
meal  is  lunch,  or  equally  good  at  dinner.  It  should  not  be  taken  with  white  or 
any  rich  sauces.  A  small  amount  of  butter  sauce  is  the  simplest  and  best.  The 
fish  most  recommended  are  sea  bass,  weak  fish,  blue  fish,  black  bass,  trout,  Span- 
ish mackerel,  sea  trout,  white  fish,  flounder,  sheepshead  and  pan  fish. 

Meat. — Meat  should  be  taken  in  a  moderate  quantity.  I  do  not  believe  in 
eating  meat  for  breakfast,  but  think  it  better  for  the  midday  or  evening  meal. 
It  is  a  question  how  often  meat  should  be  eaten.  Personally,  I  think  that 
once  a  day  is  sufficient,  but  if  partaken  of  moderately,  twice  a  day  is  not  too 
often. 

In  eating  meat,  it  is  well  to  take  a  variety  rather  than  to  confine  oneself  to 
any  particular  kind  for  everyday  consumption.  It  is  perhaps  difficult  to  define 
the  meaning  of  meat,  but  the  flesh  (that  is,  the  muscle)  of  animals  and  birds,  is 
generally  considered  as  such,  whereas,  the  internal  organs  are  not,  strictly 
speaking,  meat.  If,  then,  we  accept  the  classification  of  meat  in  its  widest 
scope,  we  have  in  beef,  steaks  of  different  cuts,  also  broiled,  roast,  stewed,  braised 
and  boiled  beef.  In  mutton,  veal,  pork  and  aninuil  game,  we  have  certain  large 
cuts  to  roast  and  boil,  whereas  the  cuts  representing  steaks,  are  called  chops 
or  cutlets. 

The  crisp,  rich  fats  that  are  on  the  outside  of  roasted  and  broiled  meats,  al- 
though agreeable  to  the  palate,  are  not  tolerated  by  the  stomach  and  should 
not  be  indulged  in  freely. 


326  UROLOGICAL   THERAPEUTICS 

In  the  bird  family,  we  have  tnrkey,  goose,  duck  (domestic  ami  wild),  fowl, 
chicken  and  sqnabs;  also  game  birds,  as  qnail,  partridge,  grouse,  woodcock  and 
plover.  All  of  the  poultry  and  game  birds  arc  usually  roasted,  but  some  of 
the  poultry  is  at  times  boiled,  while  the  smaller  game  birds  are  split  and 
broiled. 

The  internal  organs  of  animals  and  birds  are  also  edible,  as  the  liver  and 
heart,  the  kidney,  the  pancreas  and  the  thymus  (sweetbreads),  and  stomach 
(tripe),  as  well  as  the  brains  in  animals  and  the  gizzard  in  birds.  These  can 
be  cooked  in  various  ways,  but  are  not  healthy  with  rich  sauces.  They  are  gen- 
erally not  as  difficult  to  digest  as  the  muscle  flesh  is.  The  preparation  of  meat 
food  in  this  class  should  be  in  the  most  easily  digestible  way  and  they  should 
never  be  fried. 

Vegetables. — The  vegetables  recommended  in  the  simple  diet  are,  in  the 
first  class :  string  beans,  green  peas,  rice ;  in  the  second  class :  spinach,  cauli- 
flower, Brussels  sprouts  and  potatoes ;  in  the  third  class :  green  corn,  shelled 
beans,  onions,  beets,  cabbage  and  tomatoes. 

Potatoes  are  a  staple  article  of  food,  but  rich  in  starch.  They  should  be 
eaten  only  once  a  day,  baked  or  mashed.  Good  rice  is  one  of  the  most  whole- 
some and  easily  digested  articles  of  food  and  should  be  boiled  in  such  a  way  that 
the  grains  are  separated  and  it  is  dry  and  not  soggy. 

Salads. — Salads  made  of  greens  are  recommended.  They  should  be  eaten 
at  the  principal  meal  of  the  day.  The  varieties  to  be  preferred  are  lettuce, 
chickory  and  romaine,  served  with  a  French  dressing  containing  but  little  vine- 
gar and  pepper:  one  part  vinegar  to  four  parts  of  oil,  salt  and  a  very  little 
freshly  ground  white  pepper. 

Cheese. — Cheese  should  be  eaten  sparingly.  The  Stilton,  Edam,  Swiss, 
Port  Salut,  Brie  and  cream  cheeses  are  recommended. 

Sweets  and  Desserts. — Sweets  are  unnecessary  and  not  recommended.  The 
least  harmful  are  the  sago,  rice,  tapioca  and  farina  puddings,  with  very  little 
sweetening. 

Alcoholic  Beverages. — Alcoholic  drinks  are  contraindicated  in  all  cases  of 
urinary  diseases  and  yet,  if  a  patient  is  below  par  or  septic,  they  are  often  given. 
Beers  and  ales  should  be  omitted  in  all  cases,  but  light  wines  and  spirits  can 
be  given  in  moderation.  Prom  one  to  two  ounces  or  more  of  whisky  a  day  can 
be  allowed  in  certain  cases  of  chronic  nephritis  and  tuberculosis,  while  in  septic 
cases,  more  can  be  given.  A  light  Bordeaux  Avine  (claret  alone  or  mixed  with 
water)  can  be  allowed  in  almost  any  case  excepting  in  acute  nephritis  or  acute 
urethritis,  and  is  frequently  recommended  in  cases  of  chronic  cystitis.  It  should 
be  limited  to  eight  ounces  a  day.  A  light  Moselle  or  Rhine  wine  is  also  used 
in  some  chronic  cases.  This  list  is  considered  very  moderate  and  much  larger 
quantities  are  frequently  taken  habitually  or  on  special  occasions. 


DIET  327 

Direr  AT  Various  Meals 

Breakfast. — I  do  not  think  that  fish,  meat  or  vegetables  should  be  taken  for 
breakfast,  as  more  effort  is  required  to  digest  them.  Cereals  are  too  heavy  for 
many  [)eoplc,  and  frnit  too  full  of  acids  and  sugar.  I  believe  that  m/e  au  lait 
\\\{\\  rolls  or  toast  is  sufKcient  for  the  morning  meal.  If,  however,  this  is  not 
found  to  be  so,  two  eggs  and  fruit  can  be  taken.  When  the  period  between  the 
morning  and  midday  meal  is  a  long  one,  cereal  may  be  added. 

Midday  Meal. — The  amount  to  be  taken  at  the  midday  meal  depends  very 
much  on  what  has  been  eaten  at  breakfast.  If  that  has  consisted  of  simply 
a  cup  of  coffee,  milk  and  rolls,  then  fruit  and  eggs  can  be  added  to  this  second 
meal,  although  fruit  may  always  form  part  of  the  lunch. 

In  addition,  lunch,  as  I  have  said  before,  can  consist  of  oysters,  or  clams, 
consomme,  ush,  meat  or  internal  organs,  vegetables  and  cheese. 

Dinner. — The  bill  of  fare  for  dinner  may  contain  the  same  dishes  as  the 
lunch  with,  perhaps,  a  heavier  soup,  a  roast,  instead  of  broiled  meat,  and  a 
salad.     Eggs  are  not  considered  a  dinner  food  and  fruit  is  not  desirable. 

Entrees  are  frequently  not  understood  by  people  in  this  country  who  live 
away  from  the  centers  influenced  by  French,  cooking.  The  preparations  known 
as  entrees  are  stews  of  beef,  mutton  or  veal ;  meat,  poultry  and  game  cooked 
in  the  casserole ;  tenderloin  of  beef  roasted  or  cut  into  small  steaks  and  broiled ; 
saddle  of  mutton,  rib  or  loin  chops ;  sweetbreads,  kidneys,  brains  and  tripe. 
They  are  usually  cooked  with  or  served  with  some  vegetable.  I  simply  mention 
a  few  of  the  most  common  on  account  of  lack  of  space. 

The  different  varieties  of  animal  and  vegetable  food  already  mentioned,  can 
be  selected  from.  It  is  well  to  eat  sparingly  and  not  to  think  that  all  of  these 
articles  should  form  part  of  each  meal. 

It  must  be  remembered  that  these  are  guides  to  simple  food  for  people 
who  have  slight  trouble  with  the  genito-urinary  tract,  but  are  attending  to  their 
regular  work.     They  can  be  modified  accordingly. 

At  one  of  the  hospitals  at  which  I  am  attending,  the  diet  list  shows  what  is 
given  to  patients.  All  the  special  diseases  have  carefully  selected  diets  that  will 
be  found  under  that  particular  division. 

Hospital  Diet 

b'nii)  Dikt: — Milk,  l)rotlis,  bouillon,  milk  punch,  oggnog,  egg  lemonade, 
egg  albunicu,  beef  juice,  strained  gruels,  cocoa,  cocoa  shake,  koumiss,  matzoon, 
li(piid  peptonoids,  lemon  and  wine  jellies. 

Soft  Diet: — Soups  (without  vegetables),  oysters,  all  cereals,  milk  toast, 
eggs  (soft  boiled  or  poached),  milk  puddings,  ice  cream,  scraped  beef,  toast, 
junket,  tea,  coffee,  cocoa,  milk. 


328  UROLOGICAL   THERAPEUTICS 

Light  Diet: — In  addition  to  the  above:  (Jhieken,  elmps,  l)aked  ^jotatoes, 
baked  apples  and  fresh  fruits. 

For  Ward  Patients 

Breakfast  : — Tea  or  coffee,  milk  and  sngar,  cereal,  one  half  pint  of  milk, 
bread  and  bntter,  meat  or  eggs. 

Dinnek: — Sonp,  meat,  potatoes,  one  vegetable,  bread  and  butter,  one  half 
pint  of  milk,  dessert.  (Special  diet,  chicken,  chops,  broth,  etc.,  from  diet 
•kitchen.) 

Supper:- — Tea,  milk,  sngar,  bread,  toast  and  butter,  stewed  or  fresh  fruit. 
(An  extra,  meat,  eggs,  broth,  rice,  etc.) 

For  Private  Patients 

Breakfast  : — Tea  and  coffee,  cereal,  rolls,  bread  and  butter,  potatoes,  meat, 
fruit. 

Luncheon  : — Tea  and  coffee,  bread  and  bntter,  meat  and  entree.  (Re- 
mainder as  ordered.  Specially  prepared  delicacies  from  the  diet  kitchen  as 
broth,  birds,  jellies,  oysters,  etc.) 

Supper  : — Tea  and  coffee,  bread  and  butter,  soup,  meat,  oysters,  vegetables, 
dessert. 

Wards   (Complete) 

FOR    patients    in    PUBLIC    WARDS 

Regular  Diet 
Breal-fast  Dinner  Supper 

Tea,     coffee,     milk  and  Soup,     potatoes,     bread  Tea,    milk    and    sngar, 

sugar,  cereal,  one  half  and   butter,    one   half  bread,   toast  and  but- 

pint    milk,    bread  and  pint  milk.  ter,    stewed    or    fresh 

butter.  fruit. 

In  addition 

Sunday 

Oatmeal,  eggs.  Roast  beef,   extra  vege-      Oyster    or     clam     stew, 

table,  baked  custard.  cake. 

Monday 

Llominy,  steak.  Beef    stew,    extra    vege-      Cold     meat,     scrambled 

table,  bread  pudding..  eggs. 


DIET 

li 

Tuesday 

BrraJ/fasl  Dinner  Supper 

Oatmeal,  liver  aud  bacon.     Roast  beef,   extra  vege-      Boiled  Indian  meal. 

table,  sago  pudding. 


329 


Oatmeal,  steak. 


Ilominy,  eggs. 


Oatmeal,  fisli. 


Wednesday 

Roast  lamb,  extra  vege-      Gingerbread, 
table,  rice  pudding. 

Thursday 

Roast  beef,   extra  vege-     Boiled  rice  and  milk, 
table,  cornstarch  pud- 
ding. 

Friday 

Fish  or  roast  lamb,  vege-      Milk  toast,  canned  frnit. 
table,  bread  pudding. 


Saturday 

Oatmeal,  minced  meat.  Mutton    or    beef    stew.      Corn  bread. 

vegetable,   cottage 
pudding. 

Special  Orders  from  Diet  Kitchen: — Chops,  chicken  broth,  oysters,  birds, 
etc.,  jellies  and  custards. 


Peptonized  Milk  (Cold  Process). — Into  a  clean  quart  bottle,  put  pancreatiu, 
gr.  V,  and  sodium  bicarbonate,  gr.  xv  and  one  teacup  of  cold  Avater.  Shake  and 
add  a  pint  of  fresh  cold  milk.  Shake  mixture  again  and  immediately  place  on 
ice.  When  needed,  shake  the  bottle,  pour  out  required  portion  and  replace 
on  ice. 

If  the  warm  process  is  ordered,  prepare  as  above,  but  set  bottle  in  water  just 
so  hot  that  the  whole  hand  can  be  held  in  it  without  discomfort,  about  11.")^  F. ; 
keep  the  bottle  there  ten  minutes.  Then  put  on  ice  at  once  to  check  furrher 
digestion  and  keep  milk  from  spoiling. 

jSTutritive  enema : 

Peptonized  milk .^vj ; 

Egg    (beaten )    Xo.  1. 

Salt,  pinch. 


330 


UROLOGICAL   THERAPEUTICS 


EXERCISE 


331 


EXERCISE 

One  of  the  most  difficult  problems  that  we  have  to  contend  -with  is  how  to 
keep  our  walking  patients  healthy  hy  means  of  proper  exercise.  In  the  mad 
rush  of  daily  work  in  our  large  cities,  but  few  patients  will  take  the  time  during 
the  day  to  go  through  the  prescribed  exercises,  especially  those  in  the  open  air, 
which  are  exceptionally  beneficial.  Very  few  people  exercising  at  home  care 
to  go  through  many  movements  and  therefore  as  short  a  list  as  possible  should 
be  prescribed  for  them.  We  must,  therefore,  endeavor  to  have  them  take  some 
exercise  before  beginning  the  day's  work.  The  most  convenient  time  for  this 
seems  to  be  in  the  morning  on  arising,  preceding  the  morning  bath. 

The  exercises  prescribed  by  me  are  those  which  bring  into  play  and 
strengthen  the  muscles  of  the  abdomen,  back,  loins  and  thorax.  For  home  exer- 
cise I  believe  the  pulley  weights  are  the  best  for  this  purpose,  beginning  at  first 
with  the  lighter  weights  and  gradually 
increasing  them  in  proportion  to  the 
increasing  strength  of  the  individual. 

The  abdominal  exercises  are  taken 
as  follows :  Lie  flat  on  your  back  in  the 
bed  before  arising,  throw  the  bed- 
clothes over  the  foot  of  the  bed 
and   the   pillows   over   your   feet. 
Then    clasp    your    hands    behind 
your   head   and   come   to   a   sitting   pos- 
ture fifty  times  or  more  with  the  legs 
stiff.     Then  kick  aside  the  pillows  and 
bring    up    the    lower    extremities,    held 
stiff,  until  they  are  at  right  angles  with 
the  body,  for  the  same  number  of  times. 
Usually  the  patient  is  only  able  to  make 
these  movements   a  few  times   at  first, 
but  the  number  is  easily  increased   as 
the  abdominal  muscles  strengthen. 

Fig.  245  shows  exercise  in  bed,  the  patient  ly- 
ing flat  with  the  hands  l)ehiud  the  liead  and  the 
legs  stiff",  bringing  the  body  to  a  sitting  posture. 

Fig.  24G  shows  tlie  same  position  with  the 
body  and  legs  stiff,  bringing  up  the  legs  and  feet 


to  right  angles. 


Fig.  247. — Back  Exercises. 


Pulley-weight  Exercises. — The  pulley-weight  exercises  recommended  are: 
Fifst. — Stand  erect,   facing  the   pulley  weights,   with   the   arms   extended 
toward  them  (Fig.  247).     Bring  the  arms,  extended  and  stiff",  down  so  that  the 


332 


UROLOGICAL    THERAPEUTICS 


hands  will  reach  the  feet  as  nearly  as  possible  without  bending  the  knees.  Then 
swing  the  arms,  still  stiff,  over  the  head  as  far  as  possible  nntil  the  back  is  bent. 
This  swing  from  the  lowest  position  to  which  one  can  reach  to  the  highest  is 
good  for  the  muscles  on  the  front  of  the  chest  and  alxlomen  and  those  of  the 
neck  and  shoulders. 

Second. — Stand  erect,  with  the  back  to  the  pulley  weight,  with  the  arms 
extended  away  from  the  weights,  then  allow  the  arms  to  drop  to  the  sides  until 


Fig.  248. — Front  Exercises. 


the  hands  are  as  near  the  pulleys  as  possible.  Sweep  the  arms  forward  to  a 
right  angle  with  the  body  and  upward  and  backward  as  far  as  you  can  (Fig. 
248).  From  this  point  of  extension,  bring  them  down  again  to  the  position 
already  referred  to.  This  swing  is  beneficial  to  the  muscles  of  the  front  of  the 
chest  and  arms,  the  back,  the  shoulders  and  the  back  of  the  arms. 

Third. — Stand  with  one  side  toward  the  pulley  weights.  Grasp  the  handles 
with  either  hand,  both  arms  extended  toward  the  pulley  weights,  one  from  in 
front  and  the  other  from  behind  the  body  (Figs.  240  and  2.50).  Both  arms 
are  then  extended  as  far  away  from  the  pulley  weights  as  possible,  on  the  other 
side  of  the  body,  nntil  at  right  angles  to  the  side  of  the  bodv.     The  arms  and 


EXERCISE 


333 


hands  then  go  back  to  the  original  jiosition  and  the  movement  is  repeated     After 
making;  the  desired  number  of  movements,  the  other  side  of  tbe  body  is  turned 


Fig.  249. — Chest  and  Arm  Exercises. 


Fig.  250. — Chest  and  Arm  Exercises. 


334 


UROLOGICAL   THERAPEUTICS 


toward  the  piillej  weiglits  and  the  same  movements  are  made,  thus  giving  the 
same  exercise  to  both  sides. 


■■y 


Fig.  251. — Chest  and  Arm  Exercises. 


Fig.  252. — Chest  and  Arm  Exercises. 


EXEECISE 


335 


V4 


\:;>Ji^ 


The  muscles  brought  into  actiou  are  those  of  tlie  front  of  tlie  chest  and 
arms,  the  back  and  the  muscles  around  and  between  the  shoulders. 

Fourth. — Stand  with  one  side  toward  the  pulley  weights,  as  before.  Ex- 
tend both  arms  toward  the  pulley  weights  (Figs.  251  and  252).  The  arm  next 
to  tlie  weights  will  be  at  full  extension  and  at  right  angles  to  the  body.  The 
arm  away  from  the  pulleys  will  be  slightly  l)owed  over  the  chest.  Then  swing 
the  arms  held  straight  with  no  bend  to  the  elbows  around  the  front  of  the  body, 
at  right  angles  to  the  body,  to  the  other  side.  The  arm  farthest  from  the  weights 
will  then  be  extended  straight  and  the  nearer  one  will  be  bowed  over  the  chest. 
Repeat  as  many  times  as  de- 
sired and  then  turn  the  other 
side  to  the  weights  and  make 
similar  movements. 

This  exercises  the  chest 
and  abdominal  muscles,  the 
back,  the  muscles  of  the  arm 
and  under  the  arm. 

Fifth. — Stand  with  the 
back  to  the  pulleys  and  the 
feet  about  half  a  yard  apart. 
The  arms  should  be  slightly 
flexed,  the  hands  extending 
back  toward  the  machine. 
One  hand  is  then  swung 
around  in  a  circle  in  such  a 
way  that  it  passes  by  the 
front  of  the  body  at  about  the 
level  of  the  shoulder,  while,  as 
it  swings  farther,  it  passes 
around  the  body  to  the  other 

side  until  the  knuckles  point  toward  the  wall  behind.  In  making  this  swing, 
the  body  is  raised  on  the  ball  of  the  foot  on  the  same  side,  while  the  body  turns 
at  the  waist  (Fig.  253). 

This  is  the  best  movement  that  can  be  used  by  walking  urological  patients  in 
good  condition.  It  exercises  the  muscles  of  the  legs,  thighs,  buttocks,  abdomen, 
loins,  chest,  shoulder,  the  muscles  about  the  shoulder  and  the  upper  arms. 

Outdoor  Exercises. — Of  the  outdoor  exercises,  walking  in  the  fall  and  win- 
ter, and  rowing  and  swinuning  in  the  sunnuer  are  the  best.  lu  walking,  five 
miles  is  sufficient  at  a  gait  of  from  three  and  a  half  to  four  miles  an  hour.  Golf, 
when  one  is  properly  clothed,  is  an  excellent  exercise,  as  it  keeps  one  walking 
in  the  open  air.  In  the  city,  walking  to  and  from  business  each  day  is  like- 
wise beneficial. 


Fig.  253. — Loin  Exercises. 


336  rnOLOOTCAL    THERAPET'TTrS^ 

Rowing  and  swinniiiuji-  arc  of  i>,reat  licnctit:,  provided  they  iii-(!  not  too  vio- 
lently indulged  in,  or  ])rolonge<l  too  niucli.  Long  cxijo-urc  in  the  water  is 
especially  weakening. 

Tennis  is  too  violent  fi.r  many,  and  liorscljuck  or  1)i('yck'  riding  is  es])ecially 
iiijurious.  JJancing  as  an  exercise  is  Ijcneticial,  if  after  the  (hince  tlie  ])atlent 
will  retire  and  change  the  nnderwear.  Sitting  in  a  dranght  after  dancing  aiul 
eating  a  hearty  supper  before  retiring  are  not  to  he  commended.  Billiards  and 
pool  fnrnish  a  moderate  and  desirable  form  of  exercise,  as  they  recinire  tiie 
player  to  walk  around  the  table  and  stretch  over  it,  at  tlie  same  time  keeping 
the  mind  occupied  in  a  pleasant  way. 

THE    CARE    OF    THE    BOV/ELS    IN    UROLOGY 

The  care  of  the  bowels  is  most  important  in  urology,  especially  in  diseases  of 
the  bladder,  j^rostate  and  urethra.  The  venous  circulation  in  the  above-men- 
tioned organs  is  very  closely  associated  with  the  rectal  plexus,  in  consequence  of 
Avhich  a  passive  congestion  in  one  would  be  associated  with  a  passive  conges- 
tion in  the  other,  while  the  mechanical  pressure  of  the  feces  would  act  as  an 
irritant. 

In  patients  who  are  up  and  about,  this  can  usually  be  accomplished  by  regu- 
lating the  diet  and  prescribing  sufficient  exercise.  In  patients  who  are  in  a  weak- 
ened state  from  chronic  disease,  and  in  bed  patients,  this  is  more  difficult. 

The  results  of  constij^iation  are  renal  irritation  due  to  indican  and  other 
irritating  products  in  the  urine ;  joressure  on  the  prostate  and  vesicles,  and,  in 
consequence  of  this,  congestion  and  frequency  of  urination ;  while  later  on,  a 
neurasthenic  condition  may  develop. 

The  diet  in  cases  of  constipation  should  have  among  other  varieties  certain 
articles  that  leave  a  residue  as  cereals,  prunes,  spinach,  celery,  green  salad,  fruit, 
etc.     The  remaining  diet  should  be  as  usual. 

The  i^atients  on  arising  should  drink  a  lara'e  glass  of  water,  then  exercise  for 
a  quarter  of  an  hour.  (See  prescribed  exercises.)  After  this  they  should  take 
a  cold  shower  and  a  rub  down.  Breakfast  should  then  be  eaten,  after  which  the 
patient  should  go  to  stool  as  a  habit,  whether  he  feels  the  desire  or  not.  Coffee 
taken  with  breakfast  also  assists  and  many  consider  smoking  a  desirable  adjunct. 

When,  however,  the  behavior  of  the  bowels  under  the  suggested  treatment 
is  not  what  is  desired,  certain  laxatives  should  be  given.  These  are  of  two  vari- 
ties :  waters  and  drugs.  The  best  of  the  waters  are  Apenta  and  Carabaha,  half 
a  glass  (4  ounces)  of  the  former  or  a  quarter  of  a  glass  (2  ounces)  of  the  latter  is 
sufficient  to  cause  a  movement  when  the  patient  is  up  and  about.  When  the 
patient  is  in  bed,  6  ounces  of  the  Apenta  or  3  ounces  of  the  Carabaha  should 
be  given.  The  best  rule  for  bed  patients  is  to  give  them  the  aperient,  to  be 
followed  in  three  quarters  of  an  hour  by  a  light  breakfast  with  coifee  and  hot 


WATEU    A  XT)    WATER    DIET    TX    T^KOLOCY  337 

milk.  One  hour  after  breakfast,  if  the  bowels  bare  not  moved,  an  enema  of 
soapsuds  should  be  given. 

Of  the  laxative  drugs,  caseara  is  the  best.  It  is  well  to  start  in  with  the  fluid 
extract,  taking  half  a  drachm  every  night,  increasing  or  diminishing  the  dose 
accordingly.  Some  prefer  to  take  this  after  meals  in  smaller  doses,  alone  or 
mixed  with  other  drugs.  Of  the  intestinal  laxatives  having  especial  action  on 
different  parts  of  the  tract,  the  best  are  podophyllin  and  aloin.  The  first  has 
the  bettor  effect  on  the  upper  part  of  the  intestine,  the  second  on  the  lower  bi)wel. 
Nux  vomica  and  belladonna  are  good  intestinal  tonics.  In  presenting  a  com- 
bined tablet  or  pill,  aloes,  belladonna  and  nnx  can  be  nsed ;  or  podophyllin, 
belladonna  and  nnx  ;  or  extract  of  caseara  mixed  with  one  or  all  of  them. 

The  doses  for  laxative  use  are : — Aloin,  gr.  I ;  ext.  belladonna,  gr.  -g  ;  ext. 
nnx,  gr.  ^ ;  ext.  podoph.,  gr.  -| ;  ext.  caseara,  grs.  2. 

If,  in  walking  patients,  the  bowels  do  not  move  after  breakfast  with  the 
aperient  waters  or  drugs,  a  glycerin  suppository  can  be  introduced.  This  will 
usually  induce  a  movement  in  from  three  to  five  minutes.  In  case  it  fails  a  6-  to 
8-ounce  bottle  of  Red  Raven  splits  can  be  taken  three  quarters  of  an  hour  be- 
fore the  midday  meal.  For  cases  with  acute  pelvic  trouble  the  aperient  waters 
are  the  best  and  aloin  is  contraindicated. 

For  those  who  do  not  have  pelvic  trouble,  caseara  and  other  drug  laxatives  are 
the  best.  Purges  can  be  occasionally  taken.  Castor  oil  (half  an  ounce  in  sarsa- 
parilla)  is  given,  if  there  is  intestinal  fermentation  with  frequent  and  unsatis- 
factory movements,  and  calomel,  grs.  3  to  5,  in  other  cases. 

In  preparing  patients  for  operation,  surgeons  differ.  Some  give  calomel  or 
compound  cathartic  pill,  followed  next  morning  by  magnesia  sulphate,  .jss, 
while  others  give  simply  licorice  powder,  and  citrate  of  magnesia  on  the  follow- 
ing day. 

In  giving  calomel,  it  can  be  prescribed  in  ^ig-grain  doses  every  hour  for 
ten  hours ;  or  |-  grain  every  half  hour  for  four  hours ;  or  -J-  grain  every  hour  for 
six  hours  or  3  to  5  grains  at  one  time.  In  any  case,  magnesia  sulphate,  half  an 
ounce,  or  Apenta,  4  ounces,  or  Carabaiia,  2  ounces,  should  be  given  on  the  fol- 
lowing morning,  followed  by  an  enema. 

After  the  operation  calomel  can  be  given  with  soda  bicarbonate  in  any  of 
the  above  doses,  followed  by  magnesia,  and,  if  the  bowels  do  not  move,  by  an 
enema  of  soapsuds.  In  nearly  all  my  postoperative  cases  I  prefer  to  give 
Apenta  water  from  4  to  6  ounces  every  morning  and  to  follow  it  in  three  quar- 
ters of  an  hour  by  a  coft'ee  with  milk,  and  toast  breakfast. 

WATER   AND   WATER  DIET   IN   UROLOGY 

Plain  water  is  without  doubt  the  healthiest  beverage  for  mankind.  The 
majority  of  city  dwellers  do  not  drink  it  as  they  should.     In  fact,  a  great  many 


338  UKOLOGICAL   THEEAPEUTICS 

of  the  city  people  drink  tea,  coffee,  beer  or  ale  with  tlieir  meals,  and  nothing  be- 
tween meals,  while  many  others  drink  iced  water  at  meal  times  and  between 
meals.  Frequently  clinic  patients,  when  I  tell  them  to  drink  water,  answer  that 
they  do  not  like  it  and  never  drink  it. 

Water  is  rapidly  absorbed  into  the  blood,  increasing  the  amount  of  fluid 
plasma,  and  is  eliminated  chiefly  through  the  kidneys  and  the  sweat  glands. 
An  increased  amount  of  water  taken  daily  flushes  the  kidneys  and  helps  elimina- 
tion through  the  skin.  A  normal  person  should  drink  about  three  pints  daily, 
the  exact  quantity  varying  with  the  season,  the  amount  of  exercise  and  the 
weight  of  the  individual. 

Varieties  of  Water. — A  number  of  varieties  of  water  are  used:  (1)  Dis- 
tilled water,  (2)  rain  water,  (3)  city  water,  (4)  spring  water,  (5)  well  water, 
(6)  mineral  water.  The  purest  of  them  undoubtedly  is  distilled  u'Citer,  and  in 
the  absence  of  a  pure  natural  water  this  may  serve  for  drinking.  Xext  in  purity 
comes  rain  water,  which  makes  an  excellent  drinking  water  if  collected  in  the 
country,  or,  if  filtered  to  remove  dust,  in  the  city.  City  water  comes  from  lakes 
and  rivers  usually  at  a  distance,  and  is  stored  in  reservoirs  and  led  through 
aqueducts.  City  water  not  only  is  apt  to  be  contaminated  with  germs,  but  also 
to  contain  unpleasant  mineral  constituents,  giving  it  a  peculiar  taste  or  cloudy 
look ;  besides  this,  it  may  contain  lime  salts  which  render  it  "  hard."  Such 
water  should  not  be  drunk  unless  it  is  filtered  and  boiled. 

Well  ivater  is  apt  to  be  polluted  by  sewerage  unless  the  well  is  properly 
constructed  with  cemented  brick  walls  and  dug  deep  enough  to  avoid  tapping 
contaminated  water  (over  30  feet  as  a  rule). 

Spring  ivater  is  a  pure  and  clear  water  which  always  contains  more  or  less 
mineral  matter  and  in  reality  is  a  mineral  water.  Spring  water  is  derived 
from  rain  water  which  percolates  through  the  ground  until  it  strikes  an  impervi- 
ous stratum  (rock),  when  it  flows  along  this  stratum  until  it  finds  an  outlet  in 
an  unevenly  leveled  spot. 

Water  Diet. — Two  quarts  of  fluid  should  be  taken  daily,  of  which  three 
pints  should  be  water.  Water  should  be  taken  as  follows :  one  glass  on  arising ; 
the  second  at  11  a.m.;  the  third  at  lunch;  the  fourth  at  5  p.m.;  the  fifth  at 
dinner  and  the  last  on  retiring.  The  time  when  water  is  drunk  makes  a  decided 
difference  in  its  action.  Water  taken  between  meals  on  an  empty  stomach  has 
a  diuretic  action  and  tends  to  make  the  drinker  thin.  Water  drunk  with,  the 
meals  has  no  diuretic  effect  and  tends  to  increase  the  drinker's  weight.  After 
operations  on  the  lower  urinary  tract,  the  patient  should  drink  large  quantities  of 
water.  If  he  vomits  it,  more  should  be  gi^-en.  I  often  give  a  gallon  of  water 
during  the  first  twelve  hours  after  a  prostatic  operation. 

Mineral  Waters. — A  mineral  water,  in  the  sense  in  which  this  term  is  used 
by  physicians,  is  one  M-hich  contains  a  sufficient  amount  of  mineral  matter  to 
produce  a  distinct  physiological  action  aside  from  that  of  the  simple  solvent  or 


WATEE   AND   WATER   DIET   IN   UROLOGY  339 

drinkable  (piality  AViitci'.  In  1lie  strici  sense,  liowevei',  any  waler  containing  min- 
erals, as  spring  water,  is  a  mineral  water.  The  classes  of  mineral  waters  used 
in  nrology  are: 

1.  Tahlc  tralcrs:  Indifferent  or  nentral  waters  containing  little  mineral 
matter  and  acting,  in  virtue  of  their  carbon  dioxid,  as  a  pleasant  beverage. 

2.  Alkaline  waters:  Contain  carbon  dioxid,  sodium  and  magnesium  bicar- 
bonates. 

3.  Alkaline  chlorid  waters:  Contain  in  addition  sodium  chlorid. 

4.  Earthy  waters:  Charged  with  carbon  dioxid,  contain  earthy  carbonates 
and  sulphates  (calcium,  magnesium). 

f).  Alkaline  sodium  ivaters:  Contain  sodium  sulphate  as  chief  ingredient; 
besides  sodium  bicarbonate  and  chlorid. 

6,  Litliia  waters:  Contain  lithium  salts. 

7.  Bitter  laxative  ivaters:  Contain  magnesium  and  sodium  sulphates  chiefly. 

1.  Table  Waters. — The  class  of  mineral  waters  usually  known  as  tahle 
wafers  are  mild  diuretics  and  stimulants  to  digestion  and  circulation,  owing 
to  their  carbon  dioxid,  and  can  be  given  to  patients  as  palatable  beverages. 
Among  these  are  the  Poland  Spring  (Maine)  and  Great  Bear  Spring  (ISTew 
York)  waters,  that  contain  but  a  small  amount  of  alkalies.  A  more  alkaline 
water  often  used  at  table  in  this  country  is  White  Rock  Spring  water  (Wau- 
kesha, Wisconsin),  containing  an  appreciable  amount  of  alkaline  carbonates. 
The  Apollinaris  of  Ahrweiller  (Prussia),  the  Dorotheenquelle  at  Carlsbad  (Bo- 
hemia), the  Rosbach  and  Selters  waters  (Germany),  the  Halvern  Springs  water 
(England),  Condillac  (France)  and  Geyser  Spa  of  California  are  other  exam- 
l)]es  of  simple  carbonated  waters. 

2.  Alkaline  Carbonated  Waters  (Containing  Carbon  Dioxid  and 
Sodium  and  Magnesium  Bicarhonates  as  Chief  Ingredients). — These  include 
Saratoga  Vichy  (jSTew  York),  the  Prencli  Celestine  Vichy,  the  Salzbrunn  water 
and  the  ISTeuenahr  water  (Germany).  Celestine  Vichy  has  in  my  practice 
jiroved  to  be  the  best  general  alkaline  water  that  I  have  given. 

These  waters  are  indicated  in  inflammatory  conditions  of  the  urinary  tract, 
especially  of  the  bladder,  in  oxaluria,  in  gout  and  uric-acid  diathesis  and  in  cal- 
culous formation.  They  are  diuretics,  and  antacids  in  the  urine,  rendering  it 
alkaline.  They  also  dissolve  away  mucus,  allay  inflammation  in  the  bladder 
and  act  as  solvents  for  uric-acid  concretions.  They  diminish  the  excretion  of 
oxalic  acid. 

-3.  Alkaline-murlyted  Waters. — The  alkaline-muriated  waters,  which 
contain  sodium  chlorid  in  addition  to  carbonates,  are  also  useful  in  chronic 
catarrhs  of  the  bladder  and  renal  pelvis.  These  include  the  waters  of  Selters 
and  Ems,  Saratoga  Vichy  (New  York),  Plymouth  Rock  Spring  (Michi- 
gan), etc. 


340  rKOLOairAL    TTTEKAPFJ-'TTr'S 

4.  Earthy  Watkus. —  EaiMhy  wnlci-s  contaiiiiiii:'  laruc  ainonnts  (if  calciinii 
aiul  niaiiiiesium  (earhoiuilcs  and  siil|iliat('),  witli  cai'hoii  dioxid  and  small 
amounts  of  iron.  They  are  especially  useful  in  chronic  conditions  associated 
with  an  abundant  secretion  of  mucus,  especially  in  chronic  gonorrhea,  in  per- 
sistent cystitis,  neuroses  and  hemorrhages  of  the  bladder.  They  are  contraiudi- 
cated  in  the  presence  of  calcium  phosphate  or  carbonate  calculi,  in  which  sim])le 
carbonic-acid  waters  are  best  (Geyser  Spa,  Apollinaris,  Selters).  The  eai-tliy 
waters  include  a  large  nund:)er  of  springs  here  and  abroad : 

France :   Contrexeville. 

Bohemia :  Marienbad. 

Germany :  Wildungen. 

United  States:  ]S^apa  Soda  Springs  (California),  Kichfield  Springs  (Xew 
York),  Mt.  Clemens  Spring  (Michigan),  AUouez  and  Waukesha  Springs  (Wis- 
consin), etc. 

5.  The  Alkaline  Saline  Mineral  Waters  {Sodium  Sulphate  ^Yaters). 
— These  waters  are  of  great  value  in  gout,  in  lithemia,  in  urinary  calculi,  in 
obesity  and  in  chronic  nephritis,  especially  with  albuminuria. 

They  usually  contain  CO2  and  besides  sodium  sulphate  also  sodium  bicar- 
bonate and  chlorid.  They  should  be  taken  before  meals,  never  during  or  after 
meals,  in  amounts  of  from  6  to  40  ounces  (Kisch).  They  are  markedly  diu- 
retic, and  in  large  amounts  are  purgative.  They  retard  nitrogenous  metabo- 
lism and  increase  the  waste  of  fat.  They  are  also  solvent  of  uric  acid.  The 
following  are  the  principal  waters  of  this  class : 

Austria :  Carlsbad,  Marienbad,  Franzensbad. 

Switzerland :  Tarasp. 

Canada:  Caledonia  Springs  (Ontario). 

United  States :  Springdale  Seltzer  Springs,  Boulder  County,  Colorado ; 
Topeka  Mineral  Wells,  Kansas,  Geyser  Spa  (Hot),  Sonoma  County,  Califor- 
nia, Idaho  Hot  Springs,  Clear  Creek  County,  Colorado, 

The  Carlsbad  Sprudel  salt  is  sold  in  bottles  in  this  country  for  the  prepa- 
ration of  an  artificial  solution  resembling  the  original  water. 

6.  LiTiiiA  Waters. — These  contain  usually  very  small  amounts  of  lilhia 
and  are  used  principally  as  uric-acid  solvents.  Whether  they  actually  dissolve 
stones  is  not  yet  positively  known.  They  are  diuretic  and  useful  in  gout,  and 
stone  in  the  kidney  due  to  accumulations  of  uric  acid.  They  are  usually  taken 
in  the  morning,  the  dose  being  from  4  to  40  ounces  (Kisch). 

The  chief  foreign  lithia  springs  are  at  Saltzbrunn,  Homburg,  Baden-Baden, 
Ems  and  Kissingen.  A  number  of  lithia  springs  exist  in  this  country,  includ- 
ing those  in  Arkansas  (Lithia  Springs),  in  IMassachusetts  (Ballardville),  in 
ISTew  Hampshire  (Londonderry  Lithia),  in  ]^ew  York  (Saratoga)  and  in  Yir- 
ginia  (Buffalo  Lithia  Spring). 


USE    OF    WATER    IN    UllOLOCJV  34 1 

7.  Bitter  Laxativk  Waters. — TIkjsc  coutuiii  c-liiclly  .sudiiiin  ,sulj>hate  and 
magTiesiuiii  sulphate,  hut  also  magnesium  and  calcium  carbonate.  Few  of  these 
contain  carbon  dioxid. 

They  are  purgative  waters  and  are  taken  in  small  doses  (3  to  8  ounces)  in 
the  morning  before  breakfast.  They  arc  of  great  value  in  emptying  the  intes- 
tines before  operations  and  in  keeping  the  bowels  clear  in  varions  condi- 
tions in  which  this  is  desirable,  as  in  prostatics,  etc.  The  principal  Ijitter 
waters  arc : 

Bohemia:   Pull n a. 

ITungary:  Alap,  llnnyadi  Janos,  Franz  J(ise})li,  Apenta,  Victoria. 

Spain :  Carabana. 

Germany :  Friedrichshall. 

United  States :  Crab  Orchard  Springs,  Kentucky. 

All  my  urological  cases,  while  bed  patients  after  an  operation,  are  given 
either  Ajoenta  or  Carabaila  water  every  morning. 


USE    OF    WATER    IN   UROLOGY 

The  Use  of  Water  Introduced  into  the  Passages  of  Excretion,  Beneath 
THE  Skin  and  into  the  Blood  Vessels 

Rectal  Irrigations. — Rectal  irrigations  with  saline  solution  are  employed  in 
a  variety  of  diseases  of  the  urinary  organs.  They  secure  a  thorough  cleansing 
of  the  bowels ;  in  shock,  they  supply  heat ;  in  uremia  and  other  toxic  conditions, 
they  remove  intestinal  toxins  and  secure  the  absorption  of  a  certain  amount  of 
salt  solution  into  the  blood.  Locally,  that  is,  applied  to  the  lower  part  of  the 
bowel,  they  relieve  pain  and  discomfort  in  the  prostate,  the  neck  of  the  bladder, 
the  vesicles  and  the  posterior  urethra.  They  allay  spasm  of  the  vesical  sphincter 
and  they  counteract  acute  in- 
flammation in  the  pelvic  organs 
both  in  tlie  male  and  female. 
The  tube  wliich  1  eni])loy  is 
called  the  recto-<>enital  tube.     It 


is    a    double-current    tube    with    a  Fig.  254.— Recto-genital  Tube. 

curved    end    (Fig.    254).        The 

inflow  part  of  the  tube  is  attached  by  a  nozzle  to  the  rubber  tubing  coming  from 
the  douche  bag,  and  extends  to  the  opening  in  its  concavity.  The  outflow  part 
begins  in  an  o])ening  on  either  side  of  the  tube  a  little  farther  from  the  tip  than 
the  inflow  aperture  and  ends  in  a  nozzle  at  the  distal  eutl  where  it  is  attached  to 
a  piece  of  tubing  carrying  away  the  fluid  into  a  basin  or  douche  pan.  The  fluid 
flows  into  the  bowel  through  the  oi^ening  in  the  concavity  and  flows  out  through 
the  side  openings. 


342 


UEOLOGICAL   THERAPEUTICS 


Technique. — For  douching  the  lower  bowel,  the  patient  lies  in  the  hath  tub 
in  a  reclining  position  (Fig.  255),  or  sits  on  a  chair  iu  a  similar  position  (Fig. 


Fig.  255. — Rectal  Irrigations.     Patient  in  bath  tub. 

256).     A  gallon  douche  bag  is  suspended  so  that  its  bottom  is  just  on  a  level 
with  the  tojD  of  the  head,  or  two  feet  above  the  pubes.     The  douche  bag  is  tilled 


Fig.  256. — Rectal  Irrigations.     Patient  reclining  in  chair. 


USE  OF  WATER  IN  UROLOGY  343 

Avitli  a  aalldii  of  salt  solution  containing  a  tablespoonfnl  of  salt  to  the  gallon, 
the  teinpci-nlurc  of  which,  ronghly  speaking,  is  as  high  as  can  be  borne  by  the 
hand,  that  is,  about  105°  to  130°  F. 

Before  iutrodncing  the  tnbe,  its  tip  should  be  lubricated  and  the  air  should 
be  expelled  from  it  by  allowing  some  of  the  solution  to  pass  through.  The  tip  of 
the  left  forefinger  is  then  introduced  just  inside  the  front  part  of  the  anal  orifice 
and  serves  as  a  guide  to  the  tnbe,  the  tip  of  which  is  gently  introduced  into  the 
rectum,  at  first  with  a  slightly  forward  and  rotary  motion.  When  it  has  passed 
u})  for  an  inch  and  a  half,  it  comes  in  contact  with  the  apex  of  the  prostate. 
The  tip  should  then  be  tilted  back  toward  the  hollow  of  the  sacrum  and  the  tube 
should  be  pushed  up  for  another  inch  and  a  half  if  the  prostate  is  to  be  treated ; 
or  for  three  inches  if  the  seminal  vesicles  are  to  be  douched.  When  treating  the 
vesicles,  the  tube  should  be  tilted  from  side  to  side,  so  that  its  inflow  opening 
lies  over  one  or  the  other  of  the  vesicles. 

After  the  tube  has  been  inserted,  the  solution  is  allowed  to  enter  the  rectum. 
Should  the  flow  seem  sluggish,  or  be  arrested,  the  tube  is  probably  blocked  by 
fecal  matter  and  it  should  be  removed  and  thoroughly  flushed  out,  when  it  can 
be  reattached  and  reintroduced. 

In  case  the  sigmoid  and  colon  are  to  be  irrigated,  the  pelvis  should  be  ele- 
vated and  the  patient  should  lie  on  the  left  hip.  If  then  the  outflow  tubing  be 
compressed,  the  solution  will  run  up  to  the  splenic  flexure.  Turning  onto  the 
right  hip  will  then  allow  it  to  gravitate  to  the  hepatic  flexure  and  sitting  up  will 
allow  some  of  the  fluid  to  gravitate  into  the  cecum.  In  urology,  douches  of  the 
lower  part  of  the  large  intestine  are  generally  used  and  it  is  rare  that  one  is 
called  upon  to  wash  out  the  entire  colon. 

Vaginal  Irrigation. — This  should  always  be  given  to  the  patient  on  her 
back  with  the  hips  elevated  and  a  douche  pan  under  the  buttocks.  The  nozzle 
should  always  be  of  sufficient  length  to  reach  well  behind  the  cervix  of  the  uterus 
and  the  tip  should  be  introduced  along  the  posterior  vaginal  wall. 

Although  many  eminent  gynecologists  maintain  that  vaginal  irrigations  are 
of  no  benefit  in  pelvic  diseases,  my  experience  has  been  quite  to  the  contrary. 
I  am  now  speaking  of  bladder  troubles  in  women  which  are  associated  with  afl^ec- 
tions  of  the  internal  genitals.  There  is  a  close  relationship  between  the  uterus 
and  its  adnexa  and  the  bladder,  and  pressure  upon  this  viscus  as  the  result  of 
inflammations  or  malposition  of  the  female  pelvic  organs,  gives  rise  to  a  variety 
of  disturbances  of  the  bladder  functions.  Hot  vaginal  douches  of  salt  solution, 
])rolonged  and  repeated  daily,  are  very  useful  in  the  treatment  of  inflammatory 
conditions  of  the  uterus  and  its  appendages  and  have  a  good  eft'ect  in  relieving 
the  bladder  symptoms  associated  with  these  conditions.  In  treating  cases  of 
cystitis  depending  on  or  associated  with  gonorrheal  and  tuberculous  affections,  I 
have  derived  the  greatest  help  from  hot  vaginal  irrigations,  especially  when  the 
internal  female  "■enitals  were  involved. 


344  UROLOGICAL   THERAPEUTICS 

Irrigations  of  the  bladder  and  the  urethra  in  women  are  the  same  as  in  men, 
although  the  catheter  is  used  in  preference  to  hydrostatic  pressure. 

EXTEKXAT.    APrLlCATlOXS    OF    WaTKR 

The  urologist  should  he  familiar  with  the  effects  of  water  at  different  tem- 
peratures, applied  externally  in  the  form  of  baths,  douches,  etc.,  as  these  meas- 
ures form  an  important  feature  of  treatment  in  urinary  diseases.  A  very  bi-icf 
outline  of  the  general  principles  of  hydrotherapy  will  be  given  here. 

Cold  water  when  applied  externally  in  the  form  of  a  tub  shower  or  tub  bath, 
is  a  vasomotor  stimulant  which  produces  contraction  of  the  superficial,  and  re- 
flexly  of  the  deep  blood  vessels.  Cold  baths  increase  the  blood  pressure  and 
stimulate  the  activity  of  all  the  organs  of  the  body ;  but  if  too  greatly  prolonged 
the  action  is  reversed ;  muscular  activity  is  decreased  and  circulation  is  retarded. 
It  is  of  value  in  treating  patients  suffering  from  genito-urinary  conditions  who 
need  a  general  stimulation,  as  well  as  increasing  the  function  of  the  pelvic 
organs. 

Heat  applied  externally  through  the  medium  of  baths,  local  or  general,  acts 
as  a  sedative,  dilates  the  vessels  and  produces  a  hyperemia  of  the  skin  and  con- 
sequent anemia  of  the  vessels  of  the  internal  organs.  Hot  sitz  baths,  in  this  way, 
tend  to  lessen  congestion  of  the  pelvic  organs.  Hot  baths  also  promote  sweating 
and  favor  the  radiation  and  abstraction  of  heat. 

Baths. — Baths  are  divided  into  general  and  local. 

General  Baths. — General  baths  may  be  classified  according  to  temperature 
as  cold,  from  50°  to  75°  F. ;  tepid,  from  75°  to  95°  F. ;  and  hot,  from  105  = 
to.  115°  F.     The  temperature  of  the  bath  room  should  be  about  70°  F. 

The  hot  tub  bath  acts  as  a  sedative  and  should  be  given  for  from  five  to 
twenty  minutes,  with  the  patient  in  a  recumbent  position.  The  best  time  to 
take  these  baths  is  before  retiring  and  the  bath  should  never  be  prolonged  suf- 
ficiently to  make  the  patient  feel  weak  or  dizzy. 

The  cold  tub  bath  is  a  stimulant  to  metabolism  and  to  excretory  activity,  as 
well  as  an  excellent  general  hygienic  measure.  It  should  be  taken  in  the  morn- 
ing and  followed  by  a  bi-isk  rub.  Its  use  is  contraindicated  in  very  weak 
patients.  The  cold  tub  bath  may  be  u'^ed  in  septic  conditions  accompanied  by 
a  high  fever,  as  it  is  employed  in  typhoid  fever.  The  bath  is  begun  at  a  tem- 
perature about  10°  lower  than  that  of  the  patient's  body  and  the  body  is  rubbed 
vigorously  while  the  patient  is  in  the  water.  The  temperature  is  reduced  to 
about  G8°  F.  within  fifteen  miniites.  The  duration  of  the  bath  should  be 
between  twenty  and  thirty  minutes.  The  head  should  be  ^vrapped  in  a  towel 
immersed  in  cool  water  before  the  patient  is  placed  in  the  tub  and  after  the 
bath  the  patient  is  to  be  thoroughly  dried  and  placed  in  a  warm  bed. 

Tepid  baths  are  to  be  taken  by  those  who  do  not  react  properly  to  cold 
baths  and  cannot  stand  the  strona'  stimulation  of  the  latter. 


USE  OF  WATER  IN  UROLOGY  345 

Sea  Baths. — Sea  bathing'  is  one  of  the  best  adjuvants  to  other  treatments  in 
chronic  urinary  diseases  of  the  urethral  canal  and  in  all  cases  in  which  we  desire 
to  ])roniote  the  general  health  as  well  as  stimulate  the  nervous  system.  They 
are  especially  indicated  in  neurasthenic  patients,  provided  they  are  strong 
enough  to  bear  them.  Surf  bathing,  aside  from  its  stimulant  thermic  influence, 
constitntes  a  general  massage  of  the  body.  Swimming  is  one  of  the  best 
exercises  that  can  be  indulged  in.  In  order  to  insure  the  fnll  benefit  of  a 
sea  bath,  a  full  reaction  mnst  be  obtained  and  the  bath  shonld  not  be  pro- 
longed nntil  the  chilly  sensations  appear.  It  shonld  be  followed  by  a  vigor- 
ous rnb. 

Salt  baths  made  by  adding  sea  salt  (2  to  5  ounces  to  the  gallon)  to  an  ordi- 
nary tub  of  water  are  in  a  measure  substitutes  for  sea  baths  and  are  stimu- 
lants to  nervous  and  glandular  activity.  They  are  indicated  in  weak  patients 
who  cannot  take  sea  baths. 

Local  Hydrotiiekapeutic  Measures. — Of  the  local  measures,  we  must 
first  mention  the  douche  or  shower.  This  may  be  a  vertical  rain  douche,  or  a 
movable  sjiray.  Tlie  temperature  used  varies  from  the  lowest  to  the  highest 
employed  in  baths,  while  in  the  ''  Scotch  douche  "  the  temperature  is  alternately 
hot  and  cold.  A  cold  shower  is  a  powerful  stimulant  and  is  applied  for  about 
one  minute,  at  from  50°  to  60°  F.  Warm  douches  are  used  as  sedatives  in 
neurasthenia.  The  "  Scotch  "  douche  applied  to  the  genitals  is  useful  in  sexual 
depression. 

Sitz  Baths. — Sitz  baths  may  be  either  hot  or  cold.  They  are  very  useful 
in  many  urological  conditions.  They  are  taken  in  a  special  tub  holding  five  to 
six  gallons,  or  enough  to  reach  the  patient's  navel  as  he  sits  in  it.  Ordinary 
washtubs  may  also  be  used.  The  hot  sitz  bath  is  sedative,  antispasmodic  and 
anodyne,  and  should  be  given  for  from  ten  to  fifteen  minutes  twice  a  day  as 
hot  as  can  be  borne.  It  is  indicated  in  all  acute  inflammatory  troubles  of  the 
pelvis,  especially  in  the  bladder,  posterior  urethra,  prostate  and  vesicles.  Cold 
sitz  baths  act  as  a  stimulant  to  muscular  contraction,  if  not  too  prolonged. 
They  are  employed  in  impotence,  sexual  debility,  spermatorrhea,  atonic  condi- 
tions of  the  bladder  and  passive  congestion  of  the  pelvic  organs.  They  should 
last  for  from  two  to  five  minutes  only  and  are  contraindicated  in  acute  inflam- 
matory conditions  of  the  bladder,  prostate,  etc. 

Wet  Pads. — A  method  of  reducing  temperature  and  inducing  profuse 
sweating  is  kno-wn  as  the  "  wet  pack."'  A  woolen  blanket  is  i^laced  upon  the 
bed  and  over  this  is  spread  a  linen  sheet  immersed  in  cool  water  and  well  wrung 
out.  The  patient  is  placed  upon  this  sheet  with  his  head  wrapped  in  a  towel 
wet  with  water  at  about  60°  F.,  his  arms  are  raised  above  his  head  and  the 
sheet  is  tucked  in  all  around  his  body ;  the  woolen  blanket  is  then  carefully 
folded  and  tucked  over  the  shoulders  and  entire  body  of  the  patient.  A  hot- 
water  bag  is  then  placed  at  the  feet.     The  pack  is  left  on  until  it  becomes  very 


346  UKOLOGICAL   THERAPEUTICS 

^val■m  and  a  second  pack,  or  several  successive  packs,  can  be  applied  until  tin; 
temperature  is  reduced. 

In  urology  the  wet  pack  is  indicated  in  febrile  states,  such  as  septicemia, 
and  in  cases  of  pelvic  inflannnations.  In  diseases  of  the  kidneys,  the  hot  pack 
is  useful  for  promoting  perspiration  and  elimination.  They  are  contraindicated 
in  patients  with  weak  hearts. 

Sponge  Balks. — The  cold  sponge  bath  is  used  as  an  antipyretic  measure  in 
place  of  the  cold  tub  bath,  when  less  active  treatment  is  sufficient,  or  when  the 
condition  of  the  patient  is  such  that  it  is  not  advisable  to  move  liim  about. 
When  frequently  repeated,  it  reduces  temperatures  to  a  considerable  degree. 
The  sponge  bath  should  be  followed  by  an  alcohol  rub,  or  some  alcohol  should 
be  mixed  in  with  the  water. 

Local  Use  of  ('old  }Vater  and  Ice. — Local  inflammatory  conditions  arc  fre- 
quently treated  by  the  external  application  of  cold  or  ice  water,  either  in  coils 
or  ice  bag,  while  the  combined  part  of  the  genito-urinary  tract  is  treated  by  cold 
water  indirectly  applied  l)y  means  of  tul)es  called  psychrophores. 

There  are  two  varieties  of  psj'chrophores,  a  urethral  and  a  rectal.  They 
are  both  hollow  metallic  tubes,  closed  at  one  end,  with  no  outlet  through  which 
water. can  escape  into  the  urinary  or  rectal  passages.  After  the  psychropliore 
has  been  introduced  into  the  urethra  or  rectum,  the  nozzle  is  connected  with 
the  pipe  from  the  douche  bag  and  the  cold  water  flows  into  the  tube  in  a  con- 
tinuous stream,  filling  the  tube,  and  escapes  by  an  adjoining  nozzle  through  a 
piece  of  tubing  into  a  douche  pan  or  basin.  The  metallic  surface  of  the  instru- 
ment is  cooled  and  communicates  the  cold  to  the  tissues  with  which  it  lies  in 
contact.  The  psychrophore  is  used  either  in  the  rectum  or  urethra  for  passive 
hyperemia  of  the  prostate  and  posterior  urethra,  especially  in  chronic  inflam- 
mation of  these  organs  associated  with  sexual  debility,  nocturnal  emissions, 
spermatorrhea  and  prostatorrhea.  Ice  bags  are  used  principally  in  cases  of 
epididymitis  complicating  gonococcal  urethritis. 

Saline  Infusion 

Salt  solution  in  the  "  physiological  proportion,"  that  is,  1  drachm  to  the  pint, 
is  introduced  into  the  body  in  such  a  way  as  to  combat  shock,  to  supply  loss  of 
fluid  due  to  hemorrhage,  or  to  cleanse  the  blood  from  various  poisons,  as,  for 
example,  in  uremia.  The  solution  is  introduced  into  the  rectum  or  cellular 
tissues,  from  which  it  is  taken  up  into  the  circulation;  or  else  it  is  injected 
directly  into  the  vein.  The  three  methods  of  introducing  saline  solutions  are 
called:  (1)  enteroclysis,  (2)  hypodermoclysis  and  (3)  intravenous  injection. 

(1)  Enteroclysis. — This  is  the  simplest  of  all  methods  and  should  always 
be  first  resorted  to  in  an  emergency  until  the  apparatus  for  the  other  methods 
can  be  prepared.     It  consists  in  the  introduction    of  a  soft-rubber  rectal  tube 


USE    OF    WATER   IN   UROLOGY 


347 


of  sufficient  caliber  liigli  up  into  tlic  bowel  and  tbe  slow  introduction  of  a  salt 
solution,  at  105°  to  110°  F.,  containing  a  teaspoonful  of  table  salt  to  a  pint 
of  water.  The  fluid  may  be  introduced  through  a  funnel  or  with  the  aid  of  an 
ordinary  douche  bag  and,  in  either  case,  the  bottom  of  the  reservoir  should  not 
be  raised  more  than  a  foot  above  the  pubes  so  as  to  avoid  the  forcible  introduc- 
tion which  might  be  followed  by  reflex  expulsion.  The  patient's  pelvis  should 
be  elevated  or  he  may  be  placed  in  the  Trendelenburg  position,  unless  it  inter- 
feres with  a  surgical  operation. 

The  saline  enema  is  an  excellent  measure  during  or  after  operations  to 
counteract  hemorrhage  and  shock,  and  some  surgeons  employ  it  as  a  routine 
jiroeedure  in  operating.  One  pint  of  this  solution  at  a  time  is  sufficient  and, 
in  case  strong  stimulation  is  required,  two  ounces  of  whisky  can  be  added. 

(2)  Hypodermoclysis. — This  consists  in  the  introduction  of  the  salt  solu- 
tion sterilized.  It  is  recommended  that  a  small  amount  of  calcium  chlorid  and 
potassium  chlorid  be  also  added  (making  what  is  known  as  Ringer's  Solution) 
into  the  cellular  tissues  through  a  hollow  tube.  The  temperature  of  the  solution 
should  be  105°  to  110°  F.  The  apparatus  needed  is  a  sterile  reservoir  of  any 
kind  connected  by  rubber  tubing  to  an  asjnrating  needle.  The  patient  is  pre- 
jjared  as  for  a  surgical  operation,  the  skin  being  scrubbed  and  disinfected  with 
alcohol  and  bichlorid.  The  apparatus  is  prepared  and  all  the  air  is  expelled 
from  the  needle  before  it  is  inserted.  The  place  selected  for  the  puncture  should 
always  be  one  where  there  is  a  great  deal  of  loose 
subcutaneous  tissue.  In  "svomen,  the  space  between 
the  breast  and  the  chest  wall  will  be  found  con- 
venient; in  men,  the  fold  of  skin  at  the  edge  of  the 
pectoral  muscle  at  the  border  of  the  axilla. 

The  fluid  should  be  introduced  very  slowly  and 
should  be  supplied  only  as  fast  as  absorption  takes 
place.  Xot  too  much 
pressure  should  be 
used  at  any  time 
and  the  vessel  should 
be  raised  only 
enough  to  cause  a 
constant  flow.  The 
amount  of  fluid  in- 
troduced at  one  time 
varies.  About  six 
ounces  can  be  intro- 
duced in  an  hour 
and  from  one  to  two  quarts  have  been  introduced  within  twelve  hours  (Fig. 
257).     Hypodermoclysis  is  especially  useful  in  septic  conditions,  in  uremia 


Fig.  257. — Hypodermoclysis.     (From  Ashton.) 


348 


UROLOGICAL   THERAPEUTICS 


and  anuria,  but,  heinc;  slowor  tliaii  otlicr  inothods,  is  less  useful  in  lu'iiiorrlin^c 
and  shock. 

(3)   Intravenous  Injection. —  In  this  method  the  sterile  saline  solution  is 
introduced  into  a  vein  at  the  Ix'nd  of  the  ell)o\v  through  a  special  cannula.     The 


•^CMe«— ^^^^^^^ 


)))"' 


W))l«liiilil))l)j})))))))))))))ll"'"' 


Fig.  258. — Intravenous  Injection. 
The  arm  is  compressed  above  the  elbow,  thus  making  veins  prominent. 

apparatus  required  is  very  similar  to  that  for  hypodermoclvsis,  excepting  that 
it  is  advisable  to  have  the  jar  graduated  to  determine  better  the  amount  of 
fluid  entering  the  circulation.  The  rubber  tubing  and  cannula  must  be  ster- 
ilized bv  boiling,  pinned  in  a  sterile  towel  and  allowed  to  remain  there  until 
needed. 

The  skin  is  prepared  as  for  operation,   a  firm  bandage  is  placed  over  the 
upper  arm  and  tied  on  the  side  selected,  thus  impeding  the  venous  flow  and 


Fig.  259. — Intr-wenous  Injection. 
Shows  the  median  basilic  exposed  and  the  ligatures  passed  beneath  it. 

causing  the  veins  of  the  forearm  and  bend  of  the  elbow  to  bulge  out  (Fig.  258). 
The  median  basilic  is  the  vein  usually  selected  because  of  its  large  size.  It  is 
a  branch  of  the  median  vein  and  passes  obliquely  inward  across  the  bend  of 


USE    OF    WATEPt    TX    UROLOGY 


349 


the  elbow  joiniua,'  with  the  eoiiiiiinii  ulnar  on  the  inner  side  of  the  elbow  to 
form  the  basilic  vein.  The  incision  is  made  over  its  middle  portion.  The 
tissues  over  it  are  dissected  awav  by  blunt  dissection  and  two  lio;atures  are 
placed  around  the  vein 
(Fig.  27>i)).  Tlie  distal 
ligature  is  tied,  the  proxi- 
mal remains  loose.  A  trans- 
verse incision  is  then  made 
in  tlie  vein  and  the  cannula 
is  inserted  into  its  lumen 
(Fig.  260,  A,  B),  while  the 
solution  is  running  out  of 
the  tube,  in  order  that  no 
air  shall  enter  the  vein.  The 
bandage  is  now  loosened,  al- 
lowing the  solution  to  run 
into  the  vein,  and  if  neces- 
sary the  proximal  ligature 
can  be  tied  around  the  can- 
nula so  as  to  avoid  leakage. 
From  one  to  three  pints  is 
allowed  to  run  into  the  vein. 
The  elevation  of  the  douche 
jar  should  be  from  three  to 
six  feet  above  the  table.  The  flow  should  be  at  the  rate  of  a  pint  in  a  half 
hour.  The  amoinit  necessary  to  inject  depends  on  the  pulse  of  the  individual, 
which  should  be  carefully  watched. 

After  the  injection  is  finished,  the  tube  is  withdrawn  and  the  proximal 
ligature  is  tied.  The  temperature  of  the  solution  should  be  kept  constantly  at 
least  105°  F.  in  the  jar,  so  as  to  secure  a  temperature  of  over  08°  F.  as  the 
fluid  enters  the  vein.  This  may  be  aecom])]ished  by  the  addition  of  fresh  hot 
solution.  A  sterile  thermometer  is  kept  in  the  jar  for  tlic  purpose  of  regu- 
lating its  contents. 


Fig.  260. — Intravenous  Injection.  A  shows  the  cannula  in 
the  vein  and  the  tube  extending  from  it  to  the  reservoir  con- 
taining the  solution.  B  shows  the  opening  in  the  vein,  the 
cannula  inserted  and  the  vein  ligated  above  and  below  the 
opening. 


CHAPTEE    XVTI 
ANESTHESIA  IN   UROLOGY 

There  are  two  varieties  of  anesthesia,  general  and  local,  the  former  of 
which  will  probably  always  be  nsed  in  most  of  the  major  operations,  while  the 
latter  will  without  donljt  be  employed  more  and  more  as  the  technique  of  its 
administration  develops. 

General  Anesthesia. — The  materials  nsed  in  general  anesthesia  are  liquids 
which  are  rapidly  diffusible  and  therefore  are  readily  transformed  into  gases 
that  are  inhaled  and  have  a  narcotic  effect  upon  the  patient.  Of  these,  the  ones 
generally  employed  are  ether,  chloroform  and  nitrous-oxid  gas. 

Ether  is  probably  the  best  and  safest  in  all  major  surgical  operations.  It 
is  administered  through  inhalers  which  are  usually  about  six  inches  in  length, 
three  inches  in  width,  and  five  inches  in  height.  Those  that  are  sold  as  the 
most  up-to-date  appliances  are  made  wholly  or  partially  of  metal  with  various 
mechanisms  for  holding  gauze  and  cotton.  The}^  can  also  be  constructed  from 
paper  folded  in  a  strip  five  inches  wide  and  fifteen  inches  long,  this  to  be 
enveloped  in  a  towel  and  then  rolled  up  in  oval  form  of  the  same  dimensions 
already  given.  In  this  inhaler,  ordinary  absorbent  cotton  or  gauze  is  placed  and 
it  is  pinned  together  at  the  top,  in  this  way  forming  a  truncated  cone.  The  in- 
haler is  placed  over  the  nose  of  the  patient  and  the  fluid  is  ])(iiircil  into  the 
inhaler  from  above,  or  from  l)elow,  either  directly  into  the  cone  or  through  some 
apparatus  leading  to  it. 

Ether  is  also  given  by  the  drop  method  through  a  special  or  a  chloroform 
inhaler,  a  process  which  takes  a  longer  time,  but  which  is  considered  safer  for 
the  patient,  as  he  does  not  receive  such  a  large  dose  suddenly. 

Chloroform  is  administei-ed  by  the  drop  method.  The  chloroform  inhaler 
is  spoon-shaped,  made  of  a  wire  frame  covered  with  gauze  or  flannel,  and  the 
liquid  is  dropped  upon  it  very  much  as  in  the  last  method  described  for  the 
administration  of  ether. 

Of  the  two  anesthetics,  ether  is  safer  on  account  of  being  a  heart  stinmlant, 
although  it  is  supposed  to  be  contraindicated  in  diseases  of  the  kidney,  in  which 
case,  chloroform  is  considered  advisable.  The  latter  is,  however,  a  cardiac 
depressant,  and  many  deaths  have  occurred  from  its  use.  In  a  large  operative 
service  covering  many  years  and  many  urological  operations,  I  have  never  had 
a  death  that  I  could  ascribe  directly  to  ether. 
350 


GENEEAL   ANESTHESIA  351 

ISTitrous  oxid  is  of  value  for  exaiiiiiiiilioiis  in  iiroloiiy  and  is  also  used  for 
brief  operations,  altliougli  ])atienls  can  and  have  been  kept  under  its  influence 
for  an  hour  or  more.  The  i>,as  is  contained  in  a  cylinder  in  a  coin])ressed  form, 
from  which  it  escapes,  on  the  turn  of  the  valve,  into  a  collapsed  rubber  balloon. 
When  this  is  tilled,  the  gas  slowly  passes  through,  the  irdialei-  and  is  breathed  in 
by  the  patient.  It  is  the  safest  of  all  anesthetics.  It  can  be  taken  on  a  full  or 
an  empty  stomach.  No  preparation  for  the  anesthetic  is  required.  There  are 
no  toxic  symptoms  following,  such  as  vomiting  and  nausea.  It  may  be  con- 
sidered harmless. 

Dr.  C.  S.  McjSTeille,  the  dentist  at  Cooper  Union,  who  has  had  unusual 
experience  -with  this  variety  of  anesthesia,  in  speaking  of  its  action  as  an  anes- 
thetic, says :  "  All  statements  in  relation  to  this  matter  can  only  be  approximate. 
In  this  office  we  have  given  it  259,000  times  since  1SG3  with  no  deaths.  Very 
few  deaths  in  nitrous-oxid  anesthesia  have  been  reported,  and  those  usually 
came  from  asphyxia.  We  have  never  had  a  death  during  an  anesthesia.  As  to 
the  advisability  of  administering  the  gas  on  a  full  or  an  empty  stomach,  I  would 
say  that,  in  my  experience  patients  have  never  vomited  during  an  anesthesia  if 
the  operator  or  his  assistant  held  the  chin  well  down  on  the  chest  of  the  patient 
and  thus  let  the  saliva  run  forward.  I ,  also  find  that  the  patients  who  come 
with  an  em])ty  stomach  are  the  only  ones  who  have  a  headache  after  taking  gas. 
Hence  I  am  in  the  habit  of  advising  them  to  take  a  light  repast  before  the  oper- 
ation. As  far  as  the  time  during  which  we  can  keep  the  patient  under  gas  is 
concerned,  I  would  say  that  I  have  kept  a  patient  under  gas  for  a  surgeon  for 
two  and  a  half  hours  without  intermission.  The  principal  thing  in  keeping 
a  ]:)atient  under  prolonged  gas  anesthesia  is  to  watch  the  respiration  and  to  give 
the  gas  so  slowly  as  to  prevent  the  system  from  being  crowded  with  the  vapor. 

"As  long  as  the  rate  of  respiration  is  satisfactory,  in  fact  as  long  as  the  ])atieut 
is  breathing,  I  do  not  care  what  the  pulse  may  be  doing.  A  man  who  kn(.)ws 
how  to  give  gas,  will  rarely  produce  the  slightest  degree  of  asphyxia.  Should 
marked  asphyxia  occur,  then  artificial  respiration  must  immediately  be  applied. 
As  a  rule,  the  patient  recovers  in  from  a  half  to  two  minutes,  but  it  may  be 
necessary  to  continue  for  a  longer  time.  I  believe  that  the  stage  of  excitement 
in  gas  anesthesia  is  produced  by  a  too  rapid  administration  of  the  gas,  and  that 
in  giving  ether,  this  stage  is  the  more  severe  and  violent,  the  more  we  croAvd 
the  anesthetic  in  the  first  stage.  The  usual  time  for  producing  a  narcosis  for 
a  tooth  extraction  is  one  minute.  In  administering  gas,  we  are  guided  purely 
by  the  physiological  effects  and  not  by  the  pressure  indicator  on  the  reservoir.'" 

The  increasing  poiJularity  of  niti-ous-oxid  gas  as  a  general  anesthetic  has 
brought  about  its  use  as  a  forerunner  to  ether  and  chloroform  in  general  anes- 
thesia, so  that  now,  especially  in  the  administration  of  ether,  gas  is  frequently 
given  first,  which  renders  the  ])atient  unconscious  in  a  few  seconds.  Then  the 
ether  is  continued  liy  ])()uring  it  intct  a  separate  section  of  ilie  inhaler  made  for 


352  ANESTHESIA   IX   UROLOGY 

this  purpose,  and  the  patient  passes  from  the  influence  of  one  anesthetic  to 
that  of  the  other  quickly  and  with  but  slight  disturbance.  The  method  of  com- 
bined anesthesia  was  introduced  by  Dr.  Thomas  Bennett,  of  Xew  York,  who  be- 
came a  specialist  in  this  branch  of  work.  IJy  his  well-devised  apparatus  and  his 
"skillful  manipulation,  he  is  able  to  give  anesthesia,  starting  with  nitrous-oxid 
gas,  continuing  with  ether  or  chloroform  and  administering  oxygen,  if  necessary, 
in  such  a  way  that  the  operator  feels  safe  and  his  composure  is  never  disturbed 
while  operating.  The  result  of  Dr.  Bennett's  pioneer  work  in  combined  general 
anesthesia  has  been  the  development  of  anesthesia  as  a  specialty,  which  has  been 
taken  up  by  a  number  of  the  younger  men  throughout  the  country. 

The  ease  of  operating  under  nitrous-oxid  gas  has  been  one  of  the  chief  in- 
centives to  find  other  easy  methods  of  using  anesthesia  and  especially  to  produce 
analgesia  without  rendering  the  patient  unconscious,  a  condition  which  no  one 
looks  upon  favorably  and  every  patient  dreads  nearly  as  much  as  the  operation. 
An  analgesic  condition  can  be  brought  about  generally  and  locally  by  certain 
drugs.  The  best  general  analgesic  is  scopolamin,  generally  spoken  of  as  the 
scopolamiu-morphin  injection;  but  drugs  which  render  the  body  analgesic  are 
rarely  used,  as  they  are  considered  dangerous  to  the  life  of  the  patient.  Local 
analgesia  or  anesthesia  is,  therefore,  preferable. 

SpI^^Ax,  AjStesthesia. — Spinal  anesthesia  has  been  used  considerably  in  the 
surgery  of  the  genital  tract,  especially  in  women.  Personally,  I  have  never 
used  spinal  anesthesia  in  urological  operations,  and,  judging  froiu  what  I  have 
observed  of  its  effect  in  the  hands  of  other  surgeons,  I  do  not  feel  inclined  to 
advocate  its  use,  although  Goodfellow,  of  San  Francisco,  and  Boyd,  of  Panama, 
have  found  it  most  satisfactory  in  their  work  of  prostatic  surgery. 

This  method  was  introduced  in  1885  by  Corning,  of  Xew  York,  and  Avorked 
out  by  Bier,  Quincke  and  Sicard.  It  consists  in  the  injection  of  a  solution  of 
eocain  (or  another  anesthetic)  into  the  subdural  s])ace  in  the  spinal  canal.  The 
effect  of  this  is  to  render  the  entire  lower  part  of  the  body  anesthetic  through 
the  action  of  the  drug  upon  the  s})inal  nerve  roots  in  the  cauda  equina. 

The  puncture  is  made  with  a  long  strong  hypodermic  needle  beneath  the 
second  lumbar  vertebra  (in  children,  the  third  )  a  little  to  one  side  of  the  median 
line.  The  patient  lies  on  his  side  with  legs  drawn  up.  The  skin  is  disinfected 
as  for  an  operation  ;  then  it  is  anesthetized  with  a  0.1-per-cent  solution  of  eocain, 
or  with  the  ethyl-chlorid  spray.  The  needle,  syringe  and  solution  are  sterilized. 
The  dose  of  eocain  is  0.01  to  0.02  gram  in  a  syringeful  of  physiological  salt  solu- 
tion with  one  drop  of  adrenalin.  The  needle  is  first  introduced  and  a  sufii- 
cient  amount  of  spinal  fluid  allowed  to  escape.  The  syringe  is  then  attached 
and  the  solution  is  slowly  injected.  The  needle  is  withdrawn  and  the  punc- 
ture closed  with  plaster.     Anesthesia  occm-s  in  ten  minutes. 

Local  Anesthesia. — Local  anesthesia  occupies  a  very  important  position  in 
urology,  as  it  renders  the  examination  and  treatment  painless  in  many  cases, 


LOCAL   ANESTHESIA  353 

iuid  oporatioiis  can  be  perforuicJ  without  pain,  or  with  a  iiiiniinuiu  ainouiit 
of  siiircriiii;'. 

The  methods  of  applying  local  anesthesia  are  by  freezing;  by  application 
to  the  mucous  membrane  or  skin ;  by  intra-  or  hypodermic  injections  or  infil- 
trations; and  by  injections  into  the  urethra,  bladder  and  tunica  vaginalis. 

Freezing  Methods. — Freezing  methods  have  been  popular  since  the  intro- 
duction of  the  ether  spray  by  Richardson  in  1860.  In  the  following  year,  lioth- 
cnstein  introduced  the  ethyl-chlorid  spray,  which  supplanted  it  and  has  been 
extensively  used  in  minor  surgery. 

Ethyl  chlorid  is  a  colorless  liquid  which  is  sold  in  glass  tubes  provided  with 
a  stopcock.  When  grasped  in  the  hand  and  the  valve  is  opened,  the  warmth 
of  the  hand  suffices  to  vaporize  the  fluid.  The  tube  is  held  at  a  distance 
of  ten  to  fifteen  inches  (25  to  40  cm.)  from  the  spot  to  be  operated,  the  fine 
s])ray  striking  the  surface,  giving  it  a  frosty  appearance  when  it  is  frozen  and 
anesthetized. 

A  number  of  other  freezing  substances  have  been  introduced  since  ethyl 
chlorid,  but  this  is  as  eifective  as  any  of  the  newer  preparations.  The  spray 
must  be  interrupted  when  freezing  takes  place,  as  permanent  damage  to  the 
tissues  may  be  brought  about  by  prolonged  freezing.  Personally,  I  rarely  use 
the  freezing  method,  as  it  is  not  as  practical,  nor  as  far  reaching  as  other  local 
anesthetics. 

The  AppLiCATioisr  or  Iisf  jection  of  Anesthetic  Solutions. — Cocain. — 
Of  the  large  number  of  anesthetic  drugs  now  known,  the  preferable  one  in 
routine  work  is  cocain.  Cocain  is  an  alkaloid  from  the  leaves  of  the  coca  plant. 
The  salt  used  in  local  anesthesia  is  cocain  hydrochlorate  and  is  spoken  of  in 
this  chapter  as  cocain.  It  is  a  white  crystalline  powder,  soluble  in  water  and 
alcohol.  It  has  an  anesthetizing  power  when  placed  upon  mucous  or  serous 
membranes  or  when  injected  into  the  tissues,  which  was  first  discovered  by 
Ivoller,  of  ]N^ew  York,  who  utilized  it  in  anesthetizing  the  eye  in  his  operations 
on  tliat  organ.  It  paralyzes  the  nerve  terminals  of  the  sensory  nerves  in  the 
skin,  the  subcutaneous  and  other  tissues,  and  also  paralyzes,  in  a  less  marked 
degree,  the  motor  peripheral  nerves. 

Domge  of  Cocain.- — The  dose  of  cocain  internally  is  1  grain  (or  0  cgm.)  ;  in- 
jcclcd  intradermically,  or  into  the  deeper  tissues,  the  dose  is  from  1  to  2  grains 
(or  ()  to  12  cgm.);  while,  on  the  skin  or  mucous  membrane  or  the  external 
genitals,  0  grains  (or  -Tt!  cgm.)  or  more  can  be  used. 

The  dose  according  to  the  strength  of  the  solution  is  as  follows:  Of  a  lOper- 
cent  solution,  di-ops  10  are  used;  of  a  4-})er-ceut  solution,  drops  25;  of  a  2-per- 
cent solution,  drops  50 ;  and  of  a  1-per-cent  solution,  drops  100. 

The  quantity  generally  used  in  this  country  for  urethral  and  bhidder  injec- 
tions is  ^  ounce  of  a  1-per-cent  solution.  Chismore,  of  San  Francisco,  used  in 
his  office  practice  for  several  years  a  3-per-cent  solution,  of  which  he  was  in  the 


354 


ANESTHESIA   m   UEOLOGY 


liabit  of  injecting  3  ounces  into  the  bladders  of  his  patients  as  a  matter  of  rou- 
tine in  crushing  vesical  calculi. 

Method  of  Administration. — In  the  hospital,  for  intradermic  injections,  wet 
use  Bodine's  tubes  put  up  by  Squibb,  each  tube  containing  1  grain  of  sterilized 
cocain  and  a  certain  amount  of  salt.  The  solution  is  made  by  breaking  the 
tube  and  adding  its  contents  to  1  ounce  of  sterile  water.  The  proportion  of 
salt  in  the  tube  is  sufficient  to  make  a  solution  corresponding  to  1  gi-ain  of  cocain 
in  1  ounce  of  normal  salt  solution.     We  can,  therefore,  see  that : 

Tube  1  (gr.  1),  added  to  water  1  ounce,  makes  a  1:  500  or  i  of  1-per-ccnt 
solution ;  the  strength  and  dose  for  intradermic  injections. 

Tube  1  (gr.  1),  added  to  water  2  ounces,  equals  a  1:  1,000  or  iV  of  1-per- 
cent solution  ;  to  be  used  for  injections  into  the  deeper  tissues. 

For  urethra  and  bladder  solutions  \  of  1-per-eeut  strength  is  used.  It,  there- 
fore, follows  that : 

Tubes  5  in  number  (grs.  5),  added  to  2  ounces  of  water,  makes  a  1:  200  or 
■J-per-cent  solution. 

Generally,  however,  the  tablets  of  cocain  are  used  for  preparing  these  solu- 
tions, especially  in  all  exploratory  and  cystoscopic  work.  Five  -J-gi-ain  cocain 
tablets  to  1  ounce  of  water,  would  make  a  1 :  200  solution,  or  ^  per  cent.  Pow- 
ders of  similar  strength  can  be  used  in  place  of  tubes  or  tab- 
lets in  making  these  solutions. 

Sterilization  of  Cocain  Solutions. — In  the  Squibb's  tubes, 
the  contents  are  sterile,  and  it  is  simply  necessary  to  break  the 
tube,    letting   the   powder   fall   into   the   sterile   water.      After 
making  solutions  from  tablets  or  powder,  they  should  be  held 
over  a  flame  and  brought  to  a  boil  once,  as  prolonged  boiling 
weakens  the  solution.     The  solution  should  be  freshly  made  be- 
fore operating,  as  cocain  solutions  spoil  quickly.     Each  powder 
of  cocain  can  contain  incorporated  in  it  the  proportion  of  salt 
sufficient   to  make  a  solution,   corresponding  to   1   grain 
of  cocain  in  an  ounce  of  normal  salt  solution  for  a  i-of-1- 
per-cent  solution,  or  by  adding  .5  grains  to  2  ounces  of 
water  a  1 :  200  solution  will  be  obtained. 

The  syringe  used  for  intradermic  and  deeper  injec- 
tions is  one  holding  cither  5  c.c.  or  10  c.c.  of  the  solu- 
tion. The  barrel  and  piston  are  both  made  of  glass. 
Both  the  syringe  and  needles  are  sterilized  by  boiling.  The  syringe  with  a 
finger  brace  is  preferable.  The  needle  and  syringe  should  have  a  simple  socket 
joint.  For  infiltration  work,  needles  bent  at  right  angles  to  the  barrels  are 
useful  (Fig.  261). 

Technique  of  Injection:  Intradermic  and  Suhdermic. — The  syringe  should 
be  held  with  the  thumb  on  the  piston,  and  the  first  and  second  fingers  should  be 


Fig.  261. —  Steinge  for 
Local  Anesthesia. 
Needle  bent  at  right 
angles. 


LOCAL   ANESTHESIA 


355 


on  the  cross  piece  of  the  barrel.  (See  Fig.  262.)  Care  should  be  taken  that  the 
pressure  is  used  only  in  the  axis  of  the  instrument  with  a  free  wrist,  so  as 
not  to  break  the  needle. 

A  method  at  our  disposal  for  incising  or  excising  diseased,   inflamed  or 
suppurating  tissues  is,  first,  to  isolate  this  area  by  surrounding  it  with  an  anes- 


FiG.  262. — Method  of  Holding  the  Syringe. 

thetized  region  carefully  mapped  out ; 
second,  to  anesthetize  a  strip  of  skin 
and  then  gradually  work  deeper,  to 
render  anesthetic  all  the  tissues  to  be 
included  in  the  field  of  operation. 

The  first  principle  to  be  observed 
is  that  the  needle  should  not  be  pushed 
forward  or  reintroduced,  save  through 
an  already  anesthetized  field. 

The  skin  and  subcutaneous  tissue 
is  best  anesthetized  by  the  following 
method  (Fig.  263).  The  needle  is 
pushed  into  the  skin   (not  subcutane- 

ously)  just  far  enough  to  cover  the  beveled  jioint.  Then  a  little  pressure  is  ap- 
plied to  the  piston  and  a  small  white  wheal  or  bleb  is  raised  which  renders  the 
skin  anesthetic.  The  needle  is  withdrawn  and  the  point  is  now  reintroduced  at 
the  distal  margin  of  the  bleb  where  a  new  bleb  adjacent  to  the  first  is  made, 
continuing  in  this  way  until  a  strip  of  anesthetized  skin  is  obtained  for  an 
incision. 

If  a  larger  area  of  skin  is  to  be  anesthetized,  we  can  use  a  modification  of 
Reclus  and  Schleich's  infiltration  motluxls  on  the  griMind  that,  if  the  subcu- 
taneous tissue  under  an  area  of  skin  be  anesthetized,  the  surface  will  also  be- 
come anesthetic  after  a  few  minutes.  Two  points  at  o]iposite  sides  of  the  area 
are  marked  on  the  skin  by  raising  blebs   (Fig.   204).      From  these  points,  a 


Fig.  263.  —  Method  of  Making  the  Blebs  in 
Intradermic  Injections.  A  shows  the  punc- 
ture of  the  first  bleb.  The  crosses  (x)  show  the 
introduction  of  the  needle  for  the  succeeding 
blebs.     Only  the  first  puncture  is  felt. 


356 


ANESTHESIA   IN   UROLOGY 


long  needle  is  introduced  in  a  radiating-  direction  into  the  siihcntaneons  tis- 
sne,  injecting  eocain  always  ahead  of  the  needle  and  lollowing  with  the 
point.      The  diagram   shows   how   the   area   is  coN'ered   suhcntaneously.      After 

a  few  minutes,  the  entire  skin  surface  over 
this  area  is  anesthetized,  which  is  espe- 
cially applicable  in  excising  nlcerated  or 
diseased  lesions  of  the  skin,  and  in  ol)tain- 
ing  skin  grafts.  Other  forms,  as  the  oval 
or  the  diamond,  can  be  injected  in  a  simi- 
lar way,  depending  on  the  shape  and  loca- 
tion of  the  area  to  be  operated. 

When  it  is  desired  to  cocainize  a  sec- 
tion of  skin  and  a  mass  of  tissue  beneath 

it,  the  oval  or  diamond  may  first  be 
Fig.  264. — The  Subcutaneous  Method  of  -,      -,  ,    i        j>  i  i   i  mi  ^i 

Anesthetizing  AN  Area  TO  BE  Operated      marked   OUt   by    four   blebs.       Then   the    CO- 

Upon.    Numbers  1  and  2  show  the  points     cain  is  injected  deeply  into  the  tissues  to 

at  which  the  needles  are  introduced  in  ra-         t         i        ^  t  •   ^      •      •        ^  i         i  i 

diating  Unes.  the  de^ijth  to  wnich  it  is  thought  that  the 

operation  will  extend,  and  while  i)roceed- 
ing  with  the  operation,  an  injection  can  be  made  from  time  to  time  into  the 
deeper  tissues  to  be  invaded.  It  is  well  to  remember  that  1 :  500  solution  is 
used  intradermically  and  1 :  1,000  subdermically. 

The  oi^erations  that  are  performed  under  eocain  are  usually  those  of  a  minor 
type,  although  many  of  a  major  nature  are  equally  successful.  It  is  principally 
indicated  in  circumcision,  meatotomy,  internal  urethrotomy,  external  urethrot- 
omy, vesical  lithotomy  and  operation  on  any  suppurative  condition  from  the 
external  urinary  meatus  to  the  mouths  of  the  ureters. 

In  kidney  work,  with  the  exception  of  cases  of  perinephritie  abscess,  a  gen- 
eral anesthetic  should  be  used.  It  is  very  difficult  to  keep  the  parts  sufficiently 
relaxed  under  eocain  anesthesia  to  deliver  a  kidney,  unless  it  is  very  small  or 
freely  movable.  I  will  take  up  the  technique  of  local  eocain  anesthesia  more  in 
detail  under  the  operations  in  which  it  is  used. 

Cocain  Foifioning. — Cocain  jioisoning  is  usually  manifested  suddenly  by  an 
attack  of  vertigo.  Often  there  is  a  partial  or  actual  collapse,  irregular,  weak  or 
fluttering  pulse,  and  cold  perspiration  on  the  surface  of  the  body.  The  attack 
may  be  followed  or  accompanied  by  vomiting;  sometimes  syncope  occurs  and 
may  last  for  a  few  minutes. 

In  a  certain  class  of  cases,  there  is  a  feeling  of  excitation,  the  result  of  irrita- 
tion by  the  drug  of  the  brain  cortex.  It  resembles  somewhat  the  period  of 
excitement  of  chloroform  anesthesia,  excepting  that  consciousness  is  not  so 
deeply  affected.  The  patient  becomes  excited,  noisy,  laughing  and  chattering 
in  incoherent  delirium.  There  is  frequently  dryness  of  the  throat,  a  heavy 
feeling  over  the  heart  and  disturbances  of  sensation,  as  a  tingling  or  numbness 


LOCAL    ANESTHESIA  357 

of  tlic  iiiiilis,  oi"  I  lie  los^  of  sense  of  slight  (»r  iiejiriui;'.  The  pupils  m.-iy  lieeome 
\vi(lel\'  (lil;ile(l  and  iiisensihle  to  li^lit.  Soiiiel  i  nies  there  is  t  wilchi  iiii'  ol  1  ho 
iimseles,  or  loss  of  reliexes,  wliik^  in  fatal  cases  there  is  usually  eonia  and  death 
due  to  ])ai'al_vsis  of  the  res])iratory  system. 

J'rcrcnilrc  ami  Palliative  Treabnent  uf  Cocain-  rui.soniny. — We  should 
always  be  on  our  guard  against  poisoning,  as  cases  hav^e  been  reported  in  which 
slightly  over  one  grain  used  hypoderniically  or  injected  into  the  serous  and 
nuicons  cavities  has  proved  fatah  The  following  precautions  are  reconnnended 
by  Eeclus : 

The  iiatient  shonld  lie  horizontally  while  being  cocainized  and  should  re- 
main in  this  position  from  twenty  minutes  to  three  hours,  according  to  the  grav- 
ity of  the  case.  Before  the  injections  are  made,  the  part  should  be  compressed 
by  a  band  above  the  locality  to  be  anesthetized,  and  this  compression  should  con- 
tinue for  a  half  hour  after  the  operation. 

If  symptoms  of  cocain  poisoning  come  on  at  any  time,  the  patient  should 
be  made  to  lie  flat;  the  heart  should  be  stimulated  by  injections  of  strychiun, 
digitalis  or  atropin,  one  or  all,  according  to  the  pulse ;  besides  which,  friction  of 
the  body  and  the  extremities  should  be  resorted  to.  Artificial  respiration  may 
be  needed  if  breathing  threatens  to  stop.  Drops  of  amyl  nitrate  should  be  imme- 
d lately  used  if  at  hand.  In  case  the  trouble  is  due  to  a  solution  in  the  bladder, 
the  viscns  should  be  emptied  and  washed  with  saline  solution.  If  there  are  con- 
vulsions, ether  inhalations  are  indicated. 

In  conclusion,  I  will  say  that  in  all  uncomplicated  cases  of  urethral  surgery 
and  in  cases  of  vesical  calculus,  cocain  can  be  used ;  but  it  is  important  to  have 
an  assistant  to  give  the  injections  and  infiltrations,  who  is  accustomed  to  the  tech- 
nique of  the  administration.  For  prostatectomies,  extirpation  of  vesical  tumors, 
nephrotomies  and  nephrectomies,  it  is  important  to  have  a  special  anesthetist  of 
the  highest  possible  grade  if  the  operator  desires  to  feel  at  ease  during  the  oper- 
ation, as  in  that  latter  group  of  cases  in  my  j)ractice,  the  hemorrhages  are  often 
alarming. 


CHAPTER    XVIII 

DISEASES  OF  METABOLISM 

URIC  ACIDEMIA 

Uricacidezniia  is  tlic  condition  in  which  an  excess  of  nric  acid  in  the  hhjod 
is  characterized  Lj  various  nervons  symptoms  and  freqnently  bv  the  local 
phenomena  known  as  gout. 

This  does  not  mean  that  an  excess  of  nric  acid  in  the  nrine  as  shown  Ijv 
its  analysis  indicates  the  uric-acid  diathesis  or  gout,  as  is  supposed  by  many. 
These  conditions  are  the  result  of  nric  acid  retained  in  the  blood  and  tissues, 
and  not  of  that  eliminated  with  the  urine.  It  may  be  said,  and  at  times  it  is 
no  doubt  true,  that  the  amount  of  nric  acid  and  urates  contained  in  the  urine 
is  in  proportion  to  that  retained  in  the  body. 

The  formation  of  uric  acid  in  the  body  and  its  role  in  disease  are  still  sub- 
jects of  discussion.  Formerly  it  was  thought  that  uric  acid  was  a  product  of 
nitrogenous  changes,  an  intermediate  between  the  foodstuffs  and  the  final 
product  of  urea.  It  is  thought  at  present  that  uric  acid  is  formed  by  oxidation 
of  nucleic  acid  and  that  foods  rich  in  nuclei,  such  as  meats,  give  rise  to  its 
formation  and  elimination  in  large  quantities.  It  is  impossible  to  know,  how- 
ever, whether  or  not  uric  acid  is  also  derived  from  some  other  constituent  of 
the  food.  Excessive  accumulation  of  uric  acid  in  the  blood  and  tissues  is  more 
frequently  the  result  of  imperfect  elimination  than  of  increased  formation. 
Uric  acid  is  a  very  insoluble  substance  and  a  slight  decrease  in  the  alkalinity 
of  the  blood  may  cause  its  retention  and  accumulation  in  the  tissues.  AVe  hold 
at  present  that  uric  acid  is  not  formed  in  tlie  kidney,  but  in  the  tissues,  in  the 
liver  and  in  the  spleen. 

The  normal  amount  of  uric  acid  in  the  urine  is  from  0.4  to  O.o2  grams  ( (3 
to  8  grains)  in  twenty-four  hours. 

The  proportion  of  uric  acid  to  urea  is  as  1  to  45. 

A  deposit  of  uric  acid  and  urates  in  the  urine  does  not  necessarily  indicate 
an  excess  of  uric  acid.  Such  a  deposit  may  occur  on  cooling,  as  the  result  of 
acid  fermentation.  Urines  of  high  acidity  may  deposit  uric  acid,  irrespective 
of  the  absolute  quantity  of  the  latter  in  the  specimen.  Whether  uric  acid  is 
really  increased  or  not,  we  can  only  know  by  quantitative  analysis. 

Uric  acid  is  increased  in  the  urine  by  an  abundant  meat  diet,  containing 
358 


URICACIDEMIA  359 

iimcli  nuclear  siil)staii('C'  and  by  a  sedentary  life,  often  the  nse  of  tea  and  coffee, 
c'ciTain  dru^s,  as  the  salicylates  and  also  in  the  following  diseases: 

1.  In  acute  fevers  and  in  most  acute  diseases. 

2.  After  an  attack  of  rheumatism  and  gout,  when  noi-mal  elimination  has 
been  reestablished. 

').  In  diseases  of  the  lungs  and  heart  accompanied  by  diminished  oxida- 
tion (pneumonia,  hydrothorax,  chronic  heart  diseases). 

4.  In  large  abdominal  tumors,  ascites,  respiratory  insufficiency. 

5.  In  diseases  of  the  liver  and  spleen. 

6.  In  pernicious  anemia  and  leukemia,  due  to  the  destruction  of  the  nuclei 
of  the  leucocytes. 

7.  In  diabetes  mellitus. 

Uric  acid  is  diminished  in  the  urine  by  a  vegetable  diet ;  after  a  diet  of  milk, 
eggs  and  dairy  products ;  after  eating  cherries  and  similar  fruits. 

It  is  also  diminished  in  chronic  diseases  of  the  kidney  and  in  other  condi- 
tions, with  a  decrease  in  the  amount  of  urea ;  in  gout,  during  acute  attacks  and 
in  chronic  wasting  diseases. 

Symptoms. — Uricacidemia  is  clinically  characterized  by  a  certain  group  of 
symptoms,  sometimes  spoken  of  as  the  gouty  state. 

Heredity  plays  an  important  part,  and  in  many  families  various  manifesta- 
tions may  be  of  frequent  occurrence. 

In  addition  to  attacks  of  gout  proper,  a  tendency  to  uric-acid  diathesis  may 
1)0  responsible  for  more  or  less  frequent  attacks  of  headaches,  neuralgias,  sciatica, 
biliousness,  affections  of  the  skin,  such  as  eczema,  etc. 

Later  in  life,  after  the  prevalence  for  many  years  of  uricacidemia,  the 
more  serious  results  of  the  disorder  become  evident.  Arteriosclerosis  frequently 
develops,  leading  to  a  fatal  termination  by  nephritis,  apoplexy,  or  aneurysm. 

The  presence  in  the  urine  of  an  excessive  amount  of  uric  acid  in  crystalline 
form  often  acts  as  an  irritant  to  the  genito-urinary  tract  and  always  renders  the 
patient  liable  to  renal  or  vesical  calculus. 

Treatment. — In  the  treatment  of  uricacidemia,  the  fact  that  gluttony  and 
errors  in  diet  are  the  most  frequent  etiologic  factors  must  be  constantly  kept  in 
mind.  The  daily  amount  of  meat  and  fat-producing  foods  must  be  reduced,  and 
a  vegetable  diet  suljstituted.  Alcohol  must  be  interdicted  altogether.  Elimina- 
tion should  be  favored  by  the  free  use  of  mineral  waters,  such  as  ApoUinaris, 
Vich}^,  Selters,  as  well  as  by  gymnastics  and  outdoor  exercise. 

The  long  list  of  useful  therapeutic  agents  includes  the  lithium  salts,  col- 
chicuni,  uricidin,  piperazin,  the  salicylates,  etc. 

URIC-ACID    DIET 

Avoid. — Bisque,  cream  and  tomato  soup;  corned,  dried,  smoked,  canned, 
])rcserved  (ir  fried  meats  or  tish.      Tongue,  ham,  veal.   ])ork,   turkev,  beef,  lob- 


360  DISEASES   OF   METABOLISM 

sters  ami  ('ral)S.  Iliglily  spiced  sauces  and  ])c|i|)crs.  Hot  rolls,  cakes  of  all 
kinds;  all  cereals,  as  oalniciil,  lioininy,  etc.;  sini])s,  sweets  of  all  kinds;  every- 
thing made  from  corn;  potatoes,  or  vegetables  rich  in  sngar,  as  beets.  (Just  suf- 
ficient sugar  to  sweeten  coffee  can  be  used.)     Strawberries,  bananas  and  melons. 

Spirits — brandy,  whisky,  gin  and  rum;  good  whisky  is  the  least  injurious, 
taken  with  meals  and  A\ell  diluted  with  water.  One  or  two  Scotch  whiskies  a 
day,  well  diluted,  can  be  taken  with  meals  or  after  them,  if  the  patient  is  below 
l^ar;  or  a  glass  of  claret  with  the  meah  Heavy  wines,  also  champagne,  Bur- 
gundy, beers  and  ales. 

May  Eat. — Oysters  and  clams,  consomme  and  thin  soups  (without  tomato), 
fish,  beef,  lamb  and  chicken,  roasted,  boiled  or  broiled,  never  fried.  Salads 
of  lettuce,  romaine  and  chicory,  with  French  dressing,  consisting  of  four  parts 
of  oil  to  one  of  Tarragon  vinegar,  salt  and  white  pepper.  Dry  toast  and  light, 
unsweetened,  dry  bread.  Green  string  beans  and  peas ;  spinach  occasionally ; 
cauliflower  and  Brussels  sprouts,  if  they  can  be  digested.  Apple  at  lunch  and 
grape  fruit  for  breakfast,  without  sugar,  are  the  least  harmful,  although  no 
fruits  are  necessary.     Lemon  is  the  least  harmful. 

]Sr.  B. — Iso  tea.     Coffee  wdth  hot  milk  for  breakfast. 

Watei^  Diet. — One  glass  of  water  on  arising ;  one  glass  at  lunch ;  one  glass 
at  dinner ;  one  between  meals ;  one  on  retiring.  Small  cup  of  mild,  black  coffee 
]nay  be  taken  after  lunch  or  dinner. 

Dietaries. — The  following  is  the  dietary  which  Sir  H.  Thompson  recom- 
mends in  calculous  affections : 

"  Fish  in  all  forms,  except  those  containing  much  fatty  matter — i.  e.,  her- 
rings, mackerel,  eels  and  the  thin  part  of  salmon.  Game  in  all  forms. 
Poultry.  Lean  meat  in  moderate  quantity.  Preparations  of  gelatin,  savory 
jelly,  or  jelly  agreeably  flavored,  but  unsweetened.  Butter  in  moderation  (this 
is  the  only  direct  form  of  fat  admitted,  fat  in  some  form  being  necessary).  An 
egg  or  two  on  account  of  their  usefulness  in  all  cooking  operations.  (The  ob- 
jection to  eggs  applies  only  to  the  yolks.)  Milk  in  strict  moderation,  and  <»nly 
with  tea,  coffee  or  cocoa.  It  is  very  undesirable  and  noxious  in  large  quantity, 
as  it  contains  a  large  proportion  of  fat  and  sugar,  and  its  casein  is  digested  with 
difficulty.  It  is  less  objectionable  when  thoroughly  skimmed.  Well-made  whole- 
meal bread.  Oatmeal.  Pearl  barley.  Macaroni  and  other  Italian  pastes. 
Some  coarse  meal  is  needed  to  act  as  an  aperient  and  prevent  constipation. 
Whole-meal  bread  is  improved  in  flavor  and  texture  by  an  admixture  of  fine 
(not  coarse)  Scotch  oatmeal,  in  the  proportion  of  about  one  quarter  to  one  third 
of  the  wdieat  meal  employed. 

"  Dry  haricots  and  lentils  are  most  nutritive  vegetables,  and  should  be 
taken  made  into  iJurees.  They  are  digested  with  ease  and  contain  much  nutri- 
tious matter.     Rice,  sago,  tapioca  and  arrowroot  are  all  useful  if  treated  as 


INDICANURIA  361 

savory  dishes,  iiiid  not  as  swoels.  Frosli  gr('(3ii  ve£2;(!tal)l('s  are  ('sj)ef'ial]_y  f!;ood. 
Frcsli  i;r('('u  ])cas  and  hi'oad  beans,  well  masticated.  Lii^lit  salads  are  permis- 
sible to  i)ers()ns  who  digest  them  easily,  but  tliey  must  not  be  taken  by  those 
who  digest  them  with  difticulty.  Celery,  sea  kale,  asparagus,  tomatoes,  potatoes 
and  artichokes  are  all  permitted;  so  also  are  api)les,  roasted  or  leaked,  witlnnit 
added  sugar. 

"  The  following  are  to  be  avoided :  Rhubarb,  gooseberries,  currants,  strawber- 
ries, raspberries,  grapes,  plums,  pears  and  all  sweet  fruit,  fresh  or  preserved. 
Saccharin  may  be  substituted  for  sugar." 

I 

INDICANURIA 

The  urine  often  contains  substances,  not  necessarily  indicative  of  very  great 
departures  from  health,  but  rather  to  be  considered  as  danger  signals,  not  to 
be  ignored  altogether.  Thus,  it  may  contain  those  known  as  chromogens, 
that  is  to  say,  bodies  which  do  not  of  themselves  color  the  urine,  but  subse- 
quently develop  a  characteristic  color  under  special  conditions,  either  on  stand- 
ing or  on  the  addition  of  agents  that  cause  oxidation. 

Indican  may  be  defined  as  the  chromogen  of  indigo  blue.  It  arises  from 
the  absorption  on  the  part  of  the  intestinal  canal  of  the  parent  substance,  indol, 
which  itself  results  from  the  decomposition  of  proteids. 

In  the  human  intestine  in  health,  indol  is  formed  in  small  amounts.  It  is  one 
of  the  products  of  the  bacterial  putrefaction  of  albuminous  compounds,  and  is 
2)liysiologically  increased  on  a  diet  rich  in  meats  or  animal  food,  containing  a  large 
proportion  of  proteid.  The  indol  thus  absorbed  by  the  intestine  becomes  in  the 
tissues  through  oxidation  a  new  substance,  indoxyl,  which  is  excreted  in  the  urine, 
as  a  rule  in  conjugation  with  sulphuric  acid — as  indoxyl-sodium  or  potassium 
sulphate — and  also  it  is  found  in  small  proportion  as  indoxyl-glycuronic  acid. 

Pathological  Indicanuria. — The  clinical  importance  of  the  presence  of  a 
large  proportion  of  indican  in  the  urine  has  been  exaggerated  by  some,  but  is 
more  apt  to  be  underrated.  Its  significance  in  the  light  of  recent  researches  can 
scarcely  be  doubted.  It  affords  valuable  evidence  of  excessive  proteid  decom- 
position in  the  presence  of  bacteria ;  these  are  the  agents  of  processes  of  putre- 
faction that  lead  to  disturbances  in  the  liver,  to  the  various  forms  of  gastritis, 
to  constipalidu  and  diarrhea  and  those  i)rocesses  of  putrefaction  and  fei-nienia- 
tion  gathered  loosely  into  the  general  idea  of  "  toxemia  and  autointoxication."' 

Experience  shows  that  an  increased  output  of  indican  is  observed  in  cases 
of  intestinal  obstruction,  associated  with  atony  and  with  a  deficiency  of  acid  in 
the  gastric  juice,  and  in  not  a  few  intestinal  disorders  dependent  on  a  dimin- 
ished flow  of  bile.  According  to  Simon,  the  deficiency  of  hydrochloric  acid  in 
the  stomach  is  intimately  associated  with  the  development  of  indican.  Thus, 
indicanuria   occurs  frecjuently   in  carcinoma   of   the  stomach,    in   subacute   and 


362  DISEASES    OF    METABOLISM 

chronic  gastritis  and  in  those  forms  of  dyspepsia  where  the  motor  power  oi 
the  stomach  is  impaired     It  is  also  present  in  typhoid  fever. 

Examples  of  excessive  albuminous  putrefaction  and  of  the  bacterial  activ- 
ity leading  to  the  formation  of  large  amounts  of  indican  in  conditions  to  be  met 
with  elsewhere  than  in  the  alimentary  tract,  are  afforded  by  cases  of  putrid 
empyema,  fetid  bronchitis  and  pulmonary  gangrene,  the  importance  of  which 
has  been  fully  set  forth  by  Von  Jaksch. 

Symptoms. — The  symptoms  of  indicanuria  are  various,  and  are  in  many 
cases  difficult  to  trace  to  their  true  relation  with  the  output  of  indol. 

In  general,  it  may  be  said  that  indicanuria  is  commonly  associated  with  gas- 
tro-iutestinal  disorders  marked  by  flatulence — the  sig-n  of  bacterial  growth — 
and  of  the  nondigestion  of  fats,  prominently  disclosed  by  alternating  attacks  of 
constipation  and  diarrhea.  A  long  train  of  symptoms,  nervous,  hepatic  and 
renal,  take  their  origin  in  putrefying  processes  in  the  intestine,  which  at  the 
same  time  give  rise  to  the  presence  in  the  urine  of  indigo-yielding  substances. 
It  becomes  necessary,  therefore,  to  examine  the  urine  for  indican  whenever  the 
signs  of  gall-stone  disease  appear,  whenever  there  is  pain  or  colic,  or  jaundice; 
and  though  the  mere  presence  of  indican  should  not  be  regarded  as  pathogenic,  it 
gives  a  clew  to  the  nature  of  the  disease  and  its  treatment.  Thus,  a  furred  tongue, 
injected  eye,  loss  of  appetite,  headache,  torpor,  both  mental  and  bodily,  tender- 
ness over  the  liver  and  abdomen,  may  occur  without  indicanuria,  but  they  may 
just  as  well  coexist  with  it,  and  such  signs  should,  lead  us  to  examine  the  urine. 

Treatment. — The  treatment  of  indicanuria  consists  of  those  remedies  which 
are  intestinal  antiseptics  and  those  which  stimulate  bile  secretion.  Xo  single 
drug  should  be  used  continuously,  more  benefit  being  derived  by  using  different 
members  of  these  groups  from  time  to  time. 

Salol  is  the  most  frequently  used  and  is  given  in  doses  of  from  3  to  5  grains 
three  times  a  day  after  meals,  either  in  tablets  or  capsules. 

Beta-naphthol  and  naphthalene  come  next  in  efficiency  and.  are  given  in  doses 
of  2  to  5  grains  in  capsules  three  times  a  day,  after  meals.  Sodium  iodid  is  use- 
ful in  cases  in  which  there  are  accompanying  nervous  symptoms,  10  to  15  grains 
in  solution  being  given  three  times  a  day  after  meals.  Sodium  benzoate  is  also 
valuable  as  a  remedy  and  is  given  in  doses  of  10  to  20  grains  in  capsules  or  solu- 
tion after  meals.  In  cases  of  hyperacidity  due  to  intestinal  fermentation, 
sodium  bicarbonate  is  of  value,  10  to  30  grains  being  given  in  solution  or  capsule 
after  each  meal.  Of  the  remedies  used  when  fermentation  or  putrefaction  is 
due  to  an  insufficient  flow  of  bile,  the  gWcholate  and  taurocholate  of  sodium 
are  useful.  They  may  be  given  in  capsules,  3  to  4  grains  in  a  capsule,  after 
meals,  or  every  three  to  four  hours  during  the  day.  Phenolphthalein  has  of 
late  been  used  when  indicanuria  is  associated  with  constipation,  as  it  acts  as  a 
cholagogue  and  laxative.  It  is  given  in  capsules  or  tablets,  in  doses  of  from  5  to 
30  grains,  before  retiring. 


OXALUKIA  363 


OXALURIA 


Oxalnria  mpans  the  presence  of  an  excessive  amonnt  of  oxalate  of  calcinm 
in  the  urine.  When  found  occasionally  in  moderate  quantity,  these  crystals  are 
of  no  clinical  significance,  as  they  may  appear  under  normal  conditions  after 
eating  fruits  and  vegetables  containing  comparatively  lai-ge  amounts  of  oxalic 
acid,  such  as  rhubarb,  tomatoes,  spinach,  cabbage,  turni]^s  and  sorrel. 

Oxalic  acid  is  a  product  that  is  formed  as  an  intermediate  step  in  the  com- 
bustion process,  and  comes  between  urea  and  uric  acid  in  the  series.  It  is  found 
in  very  small  quantities  in  normal  urine  in  the  form  of  calcium  oxalate,  but  it  is 
contained  in  normal  specimens  occasionally  only,  after  the  urine  has  been  left 
standing  for  a  time. 

Urine  containing  numerous  crystals  of  calcium  oxalate  for  any  length  of 
time  is  not  the  urine  of  a  healthy  individual,  and  the  condition  is  one  that 
should  be  treated. 

Oxaluria  is  merely  a  symptom  pointing  to  a  debilitated  condition  of  the 
system.  Of  the  cause  of  this  condition,  little  is  known.  Generally,  oxaluria  is 
associated  with  conditions  of  nervous  debility,  perhaps  especially  often  with 
those  arising  from  sexual  excesses.  This  is  so  frequently  the  case,  that  one 
should  always  be  on  the  lookout  for  spermatozoa,  if,  in  examining  the  urine  of 
a  nervous  individual,  calcium  oxalate  is  found. 

Oxaluria  may  also  give  rise  to  local  irritation  in  the  genito-urinary  tract. 
When  the  crystals  are  formed  in  the  kidney  as  they  very  frequently  are,  their 
passage  through  the  kidney  tubules,  pelvis  and  ureters  may  give  rise  to  lumbar 
pains  or  hematuria,  or  the  crystals  may  collect  around  epithelial  cells  and  mucus 
and  form  into  concretions  in  the  kidney  or  renal  pelvis,  causing  renal  colic,  or 
they  may  irritate  the  bladder  and  urethra,  bringing  on  frequency  of  urination. 

The  urine  in  cases  of  pronounced  oxaluria  is  of  high  specific  gravity,  often 
reaching  1.040.  Even  when  there  are  no  subjective  symptoms  of  irritation,  the 
microscopic  examination  usually  shows  the  presence  of  red  blood  corpuscles, 
mucus  and  epithelia. 

Treatment. — Eegulation  of  the  diet,  and  exercise,  are  of  the  greatest  im- 
portance. 

The  diet  indicated  shoidd  be  one  that  limits  the  amounts  of  all  articles  con- 
taining large  amounts  of  oxalic  acid.  Water,  weak  coffee  and  tea  are  the  most 
suitable  drinks.  Alcoholic  beverages  are  not  especially  forbidden,  but  should 
be  taken  in  moderation. 

In  order  to  dilute  the  urine,  the  patient  should  drink  water  freely.  The 
carbonated  alkaline  waters,  such  as  Apollinaris,  are  especially  useful.  Many 
authors,  as  Klemperer,  Tritchler  and  others  favor  the  bitter  waters  containing 
magnesia,  such  as  Friedrichshall,  llunyadi,  etc. 

Some  cases  are  greatly  benefited  by  the  administration  of  nitromuriatic  acid. 


364  DISEASES    OF   METABOLISM 

DIET    IX    OXALURIA 

From  tlie  following  list  of  foods,  a  diet  suitable  for  })atieiit.s  having  oxaluria 
may  be  selected : — • 

Foods  Pebmitted. — Clams  and  oysters,  consomme  and  thin  sonjis  without 
tomatoes,  all  kinds  of  meat  and  jish  (baked,  boiled  or  broiled),  stale  bread  and 
toast.  Vegetables:  Fresh  string  and  lima  beans,  gi-een  peas,  lettuce,  chicory  and 
romaine  salads ;  later  on,  Brussels  sprouts  and  cauliflower  may  be  added. 
Fruits:  Apples  are  for  lunch,  peaches  or  grape  fruit  without  sugar  are  the  least 
harmful  for  breakfast  in  moderation.  Cereals:  Oatmeal,  well  cooked,  may  be 
taken  in  small  quantities. 

Foods  Forbidden. — All  vegetables  not  mentioned  in  foregoing  list ;  espe- 
cially injurious  are  potatoes,  tomatoes,  spinach,  rhubarb,  beets,  turnips,  dried 
beans.  Fruits:  Strawberries,  plums,  figs.  All  sweets  are  interdicted.  Meats: 
All  glands  such  as  pancreas,  thymus,  liver  and  kidneys,  on  accoimt  of  the  many 
nucleins  contained  therein. 

EXTRA    DIET    IX    OXALURIA 

A  More  Bigid  Diet  Covering  a  Longer  Period 

First  Week. — As  purely  nitrogenous  as  possible,  may  take  milk,  meat 
(boiled,  broiled  or  roasted),  fish,  eggs  once  a  day.  Xothing  fried,  pickled, 
salted  or  canned,  or  preserved  in  any  way.  Should  drink  pure  water,  at 
least  three  quarts  a  day.  Xothing  to  be  taken  except  those  things  men- 
tioned. 

Second  Week. — To  above  may  be  added  cucumbers,  celery,  lettuce  and 
asparagus. 

TuiRD  Week. — To  above  may  be  added  raw  oysters,  oyster  broth,  green 
peas,  string  beans,  any  broth  or  variety  of  clear  soup. 

Fourth  Week. — Grape  fruit,  lemons  and  cauliflower  may  be  added,  pears, 
peaches,  baked  apples,  grapes  in  moderation,  melons,  well-cooked  oatmeal  in 
small  amount  and  well-toasted  or  stale  wheat  bread. 

Interdicted. — Potatoes,  spinach,  rhubarb,  beets,  turnips,  dried  lieans,  to- 
matoes, strawberries,  plums,  figs,  or  sweets  added  to  the  above. 


DIABETES  AND   GLYCOSURIA 

General   Consideration 

Diabetes  and  glycosuria  are  discussed  together  in  this  eliai)ter  because  they 
are  so  frequently  confused  with  one  another,  owing  to  the  fact  that,  in  diabetes 
mellitus,  glycosuria  is  present. 


DIABETES  AXD  GLYCOSUEIA  365 

Diabetes. — Diabetes  is  a  disorder  of  tlie  body  metabolism,  characterized  by 
the  passing  of  excessive  quantities  of  urine.  There  are  two  forms  of  diabetes : 
Diabetes  mellitus  and  diabetes  insipidus. 

Diabetes  mellHus  is  the  most  important  form.  In  addition  to  the  polyuria 
and  the  intense  thirst  which  characterizes  bftth  forms  of  diabetes,  we  have  here 
the  presence  of  sugar  in  the  urine.  When  diabetes  is  spoken  of  without  quali- 
fication, this  form  is  usually  referred  to. 

Diabetes  insipidus  is  a  name  applied  to  that  form  of  diabetes  which  is 
characterized  by  the  passage  of  abnormally  large  quantities  of  normal  urine  of 
low  specific  gTavity,  and  by  intense  thirst. 

Glycosuria. — Glycosuria  means  the  presence  of  sugar  in  the  urine,  from  any 
cause,  in  excess  of  0.1  per  cent. 

There  are  three  varieties  of  glycosuria:  (1)  The  alimentary,  (2)  the  toxic, 
(3)  the  diabetic. 

Alimentary  glycosuria  occurs  in  healthy  individuals  in  certain  disturbed 
conditions  of  digestion  and  elimination ;  also  in  diseases  of  the  liver  and  of  the 
brain,  especially  when  the  latter  affects  the  fourth  ventricle ;  in  goiter  and  after 
injuries.  Alimentary  glycosuria  may  occur  after  the  ingestion  of  large  amounts 
of  starch. 

Toxic  glycosuria  occurs  in  fevers,  after  drinking  large  amounts  of  alcohol 
and  after  poisoning  with  lead,  phosphorus,  morphin,  atropin,  chloral,  amyl 
nitrite,  acetone,  carbon  dioxid,  curare  and  strychnin. 

Phloridzin  glycosuria  should  be  classed  under  toxic  glycosuria.  Although 
phloridzin  is  a  glucosid,  the  amount  of  sugar  passed  after  its  administration  is 
too  great  to  be  accounted  for  by  that  derivable  from  the  drug.  Phloretin,  which 
is  a  derivative  from  jihloridzin,  is  free  from  sugar  and  produces  the  same  result. 

Diabetic  glycosuria  constitutes  the  disease  known  as  diabetes  mellitus. 

DiABKTF.S    ^IeLLITUS 

Pathology  and  Etiology. — The  pathology  and  etiology  of  diabetes,  like 
those  of  other  disorders  of  metabolism,  has  not  been  definitely  determined.  The 
glycogenic  function  of  the  liver  is  deranged,  and  an  excess  of  sugar  passes  into 
the  blood  and  is  eliminated  with  the  urine.  The  bulk  of  the  sugar  thus  passed 
is  derived  from  the  carbohydrates  in  the  food ;  in  severe  cases,  a  certain  amount 
of  the  sugar  seems  to  be  the  result  of  metabolism  of  the  ]u-oteid  constituents  of 
proto])lasm. 

The  amount  of  sugar  eliminated  in  diabetes  varies  considerably.  It  ranges 
from  a  mere  trace  up  to  ten  per  cent  and  even  twenty  per  cent ;  average  two  to 
three  per  cent.  The  percentage  of  sugar  in  tlie  urine  is  by  no  means  an  accurate 
index  of  the  severity  of  the  pathological  process. 

The  total  amount  of  urine  passed  also  varies  greatly.     In  mild  cases,  the 


366  DISEASES    OF    METABOLISM 

daily  quantity  may  not  exceed  six  to  eiglit  pints;  in  s(!vere  cases,  thirty  to  fort}' 
pints  are  often  passed. 

The  specific  gravity  is  high,  varying  according  to  the  saccliarine  contents 
of  the  nrine  from  1.025  to  1.060. 

Diabetic  nrine  has  a  sweetish  taste  and  aromatic  odor,  increasing  or  dimin- 
ishing with  the  amonnt  of  sngar. 

Symptoms. — The  great  prominent  general  symptom  of  the  disease  is  in- 
tense thirst,  a  large  quantity  of  water  being  required  to  keep  the  sugar  in  solu- 
tion. There  is  also  usually  a  great  craving  for  food;  in  spite  of  abnormally 
large' quantities  of  nourishment  taken  and  in  spite  of  excellent  digestion,  the 
patient  may  lose  weight.  The  skin  is  dry  and  harsh,  the  temperature  frequently 
subnormal,  the  pulse  frequent  and  the  tension  increased. 

Complications. — Serious  complications  are  frequent,  such  as  acute  pneu- 
monia, tuberculosis,  diabetic  tabes,  hypochondriasis,  cataract,  diabetic  retinitis, 
impotence ;  nephritis  is  quite  common,  sometimes  due  to  arteriosclerosis,  in 
other  cases  probably  the  result  of  the  strain  on  the  renal  structure  from  the 
continual  passage  of  abnormal  quantities  of  sugar. 

Prognosis. — Recovery  from  true  diabetes  is  very  rare.  In  children,  the  dis- 
ease is  especially  fatal ;  so-called  galloping  cases  are  often  seen  which  carry  the 
young  patient  ofp  in  a  few  days.  With  advancing  years,  the  disease  runs  a 
slower  course.  During  middle  life,  diabetes  may  exist  for  ten  or  fifteen  years 
before  the  fatal  termination.  In  stout  individuals,  the  prognosis  is  more  favor- 
able than  in  those  of  slighter  build. 

Unless  one  of  the  many  serious  complications,  to  which  the  patient  is  ex- 
-  posed,  sets  in,  the  disease  usually  ends  with  diabetic  coma.  This  condition 
closely  resembles  in  its  onset  uremic  coma  and,  like  it,  is  due  to  the  presence  in 
the  blood  of  some  toxic  agent,  which  in  this  case  is  believed  to  be  acetone. 

Treatment. — The  diet  and  personal  hygiene  of  the  patient  are  of  prime  im- 
portance. The  patient  should  live  a  quiet  life,  free  from  excitement  and  worry. 
He  must  be  scrupulously  regular  in  his  habits,  taking  a  moderate  amount  of 
exercise  and  bathing  daily  to  promote  a  free  action  of  the  skin.  The  regula- 
tion and  restriction  of  the  diet  is  the  most  essential  part  of  the  treatment.  The 
carbohydrates  in  the  food  should  be  reduced  and  a  carefully  arranged  diet,  with 
due  regard  for  variety,  should  be  given.  The  substitution  of  gluten  bread  for 
ordinary  bread  and  saccharin  for  sugar,  should  be  a  part  of  the  dietary  regime. 

Among  remedies,  opium  is  the  one  that  has  specific  influence  on  the  progTess 
of  the  disease.  Codein  given  in  one-half-gTain  doses  three  times  a  day,  gTadu- 
ally  increasing  to  six  or  eight  gTains  during  twenty-four  hours,  will  in  the  ma- 
jority of  cases  lessen  the  amount  of  sugar  in  the  urine  materially.  As  the 
amount  of  sugar  diminishes,  the  opium  may  be  gradually  withdrawn. 

Among  other  useful  remedies,  we  may  mention  potassium  bromid,  arsenite 
of  bromin,  arsenic,  antipyrin,  the  salicylates,  nitroglycerin  and  strychnin. 


PHOSPHATUIIIA  367 

DIKT    LIST 

From  Friedenwald  and  Ruhrah,  ^^  Diet  in  TJeaUh  and  Disease  ^^ 

Foods  Allowed. — Meats,  eggs,  green  vegetables,  fats.  Soups:  Chicken, 
beef,  veal,  mutton,  oyster,  turtle,  terrapin,  clam  broth  (prepared  without  flour). 
Meats:  All  meats,  except  liver.  Gelatin  jellies.  Cheese:  All  varieties,  espe- 
cially cream  cheese.  Fish:  All  fish,  including  oysters,  clams,  terrapin,  lobster, 
shrimp,  salt  fish.  Farinaceous  foods:  Gluten  bread,  cakes,  biscuits  and  por- 
ridges, almond  cakes  and  bread,  soya  bread.  Vegetables:  Green  vegetables, 
spinach,  lettuce,  romaine,  chicory,  sorrel,  kale,  artichokes,  endives,  pickles, 
cucumbers,  cranberries,  truffles,  mushrooms.  Fruits:  All  acid  fruits,  sour  ap- 
ples, sour  cherries,  sour  oranges,  lemons,  grape  fruit,  gooseberries,  red  currants. 
Nuts:  All  sorts  of  oily  nuts,  such  as  cocoanut,  walnuts,  filberts,  almonds,  butter- 
nuts, pecans,  Brazil  nuts.  Fatty  foods:  Cream,  butter,  olive  oil,  cod-liver  oil, 
bone  marrow.  Drinks:  Tea  or  cofPee  without  sugar,  alkaline  mineral  waters, 
Rhine  wines,  claret.  Burgundy,  brandy,  whisky. 

Foods  Forbidden. — Sugars,  starchy  foods  (rice),  sweets  of  all  kinds,  liver. 
Vegetables:  Potatoes,  turnips,  beets,  carrots,  peas,  baked  beans,  cauliflower;  also 
sweet  fruits,  such  as  dates,  grapes,  peaches,  prunes,  bananas,  preserves  and  jel- 
lies. Nuts:  Peanuts  and  ckestnuts.  Drinhs:  Sweet  wines,  cider,  cordials,  beer, 
porter. 

PHOSPHATURIA 

This  is  a  condition  in  which  an  excess  of  phosphates  is  passed  in  the  urine. 
Two  varieties  of  phosphaturia  can  be  distinguished,  the  true  and  the  false.  True 
phosphaturia  depends  upon  an  absolute  increase  in  the  amount  of  phosphates 
eliminated  in  the  urine  as  determined  by  quantitative  analysis. 

A  mere  deposit  of  phosphates  in  the  urine  immediately  on  voiding  or  on 
standing,  without  a  relative  increase  in  the  total  amount  of  phosphates,  consti- 
tutes false  i^hosphaturia.  The  clinical  diagnosis  of  true  phosphaturia  can  be 
made  only:  (1)  If  there  is  a  quantitative  excess  of  phosphates  which  is  con- 
stant (the  normal  amount  excreted  in  twenty-four  hours  does  not  exceed  three 
and  a  half  to  four  grains).  (2)  If  this  excess  is  not  controlled  by  a  change  of 
diet.  (3)  If  the  deposit  of  phosphates  occurs  immediately  after  voiding  the 
urine. 

Deposits  of  phosphates  in  the  urine  may  occur  within  the  body  in  cases  of 
inflammation  or  suppuration  of  the  urinary  organs,  such  as  cystitis,  pyelitis, 
etc. ;  es}D€cially  when  there  is  a  decomposition  of  the  urine  within  the  tract, 
the  result  of  an  obstruction,  as  an  enlarged  prostate  or  a  stricture.  Of  course, 
such  cases  cannot,  in  any  sense,  be  called  true  phosphaturia. 

This  form  of  phosphaturia  is  of  special  interest  to  the  genito-urinary  surgeon 
on  account  of  the  frequent  formation  of  calculi  under  these  conditions. 


368  DISEASES    OF   :\rET ABOLISH 

The  iDliospliorus  eliiiiinaic'(l  with  the  urine  is  derived  from  two  sources: 
from  the  food  and  from  decomposition  <if  the  tissues,  especially  the  jjliDsphorus 
containing  proteids,  as  well  as  nuclein  and.  lecithin. 

In  the  urine,  the  phosphorus  appears  in  two  forms:  (1)  As  earthy  phos- 
phates—calcium and  magnesium  phosphates;  (2)  as  alkaline  phosphates — the 
phosphates  of  sodium  and  potassium.  The  alkaline  ijhosjthates  are  more  abun- 
dant, the  proportion  being  about  two  to  one. 

The  earthy  phosphates  are  held  in  solution  in  the  urine  Ijy  the  diacid  sodium 
phosphate,  to  which  the  acidity  of  the  urine  is  due. 

Whenever  the  acidity  of  the  urine  is  neutralized,  either  before  or  after 
voiding,  the  earthy  phosphates  are  precipitated,  but  they  can  readily  be  dis- 
solved by  making  the  urine  acid  again. 

A  vegetable  diet,  by  diminishing  the  acidity  of  the  urine,  will  often  Ijring 
about  this  apparent  phosphaturia ;  while  a  meat  diet,  on  the  other  hand,  will 
decrease  or  cause  the  disappearance  of  this  precipitate  of  earthy  phosphates  by 
increasing  the  acidity  of  the  urine. 

True  i3hosphaturia,  that  is,  the  condition  associated  with  a  more  or  less  con- 
stant relative  increase  in  the  amount  of  phoephorus  eliminated,  must  be  classed 
as  a  disorder  of  metabolism.  According  to  L,  J.  Teissier,  four  forms  of  this 
disease  can  be  distinguished: 

1.  Cases  with  polyuria  and  with  very  pronounced  disturbances  of  the 
nervous  system,  with  or  without  organic  changes  in  the  latter. 

2.  Cases  which  are  from  the  beginning  or  during  the  later  stages  of  the 
disease  associated  with  fatal  affections  of  the  lungs. 

3.  Cases  in  which  phosphaturia  occurs  together  or  alternate  with  glycosuria. 

4.  Cases  which  cannot  be  grouped  under  the  foregoing  divisions  and  which 
alternate  with  oxaluria  and  uricacidemia,  showing  often  also  a  slight  albu- 
minuria and  a  certain  relation  to  gouty  states. 

Treatment. — The  treatment  of  phosphaturia  requires,  first  of  all,  regidation 
of  the  diet  and  habits  of  living,  whether  the  disorder  belongs  to  the  true  or  false 
variety.  Among  the  remedies  that  have  been  used  successfully  in  the  control  of 
true  phosjDhaturia,  phosphorus  is  especially  recommended,  also  nux  vomica 
and  arsenic. 

To  control  phosphaturia  of  the  false  variety,  the  conditions  producing  it 
must  be  treated.  There  may  be  decomposition  of  the  urine  in  the  urinary 
tract,  due  to  inflammation  and  obstruction.  ]\Iany  cases  of  false  phosphaturia 
simply  require  a  more  liberal  meat  diet ;  others  call  for  mineral  acids  to  cor- 
rect gastric  fermentations  and  disturbances  of  the  digestive  function.  If  the 
phosphaturia  is  accompanied  by  bacteriuria,  urotropin  should  be  given. 

The  diet  list  for  a  case  of  phosphaturia  may  contain  meat,  eggs,  milk, 
cheese,  cereals  and  the  legumes,  whereas  the  ingestion  of  fresh  gTeen  vegetables, 
fruit  and  potatoes,  should  be  restricted. 


CHAPTEE    XIX 

METHODS  OF  EXAMINING  THE  KIDNEY 

In  the  cases  that  we  are  called  upon  to  see,  we  are  led  to  suspect  the  pres- 
ence of  a  surgical  disease  of  the  kidney  by  certain  symptoms,  foremost  of  which 
is  a  complaint  of  pain  in  the  loin ;  second,  symptoms  referable  to  urination  or 
the  urine  voided;  and  third,  constitutional  symptoms. 

Pain  is  the  most  important  of  these  troubles.  It  may  be  slight  in  char- 
acter and  may  be  present  constantly  or  at  intervals,  or  it  may  come  on  as  a  severe 
attack  of  colic  located  in  the  loin  and  extending  down  the  course  of  the  ureter. 

Pain  is  most  common  in  renal  calculus,  especially  after  exertion,  although 
it  is  also  present  in  varying  severity  in  movable  kidney,  tuberculosis  and 
nephralgic  nephritis. 

Prequent  and  painful  urination  is  a  bladder  symptom  and  rarely  occurs  in 
kidney  disease,  excepting  in  renal  tuberculosis  in  cases  in  which  the  disease  has 
invaded  the  bladder.     Polyuria  is  also  a  symptom  of  renal  tuberculosis. 

Hematuria  is  the  symptom  of  renal  disease  which,  next  to  pain,  alarms  a 
patient  the  most  and  is  the  reason  for  the  consultation.  When  hematuria  occurs 
in  a  patient  suffering  from  pain  in  one  loin,  it  leads  us  to  think  of  hematuria 
on  that  side.  Plematuria  is  most  characteristic  of  renal  tumor,  in  which  case 
it  is  spontaneous  and  often  very  severe.  !Rext  in  order,  it  occurs  in  renal  calcu- 
lus and  tuberculosis. 

Pyuria  in  kidney  cases  means  infection,  as  does  also  fever,  and,  therefore, 
if  cither  or  both  of  these  symptoms  occur  in  a  patient  with  pain  in  the  loin,  it 
leads  us  to  think  of  a  septic  kidney.  With  the  history  of  these  symptoms,  we 
must  begin  the  examination  that  will  finally  lead  to  the  diagnosis  of  the  trouble. 

In  the  examination  of  a  suspected  case  of  surgical  kidney,  several  questions 
have  to  be  taken  into  consideration.  First,  Are  the  kidneys  affected  or  is  the 
trouble  in  some  of  the  other  urinary  organs  ?  Second,  Which  kidney  is  dis- 
eased ?  Is  there  another  kidney  ?  If  there  is,  What  is  its  condition  ?  Th  ivd. 
What  is  the  nature  of  the  disease  ?  Fourth,  What  is  the  functional  power  of 
■  the  diseased  kidney  and  its  mate  ?    Fifth,  Is  an  exploratory  operation  necessary  ? 

No.  1:  The  Examination  of  the  Urine. — This  is  most  important  when  con- 
i  sidered  in  conjunction  with  other  findings.     The  presence  of  normal  renal  prod- 
ucts in  the  urine  in  an  increased  amount,  or  of  abnormal  products,  both  point 

369 


370  METHODS    OF    EXAMINING    THE    KIDNEY 

to  a  renal  disturbance.  If  we  find  a  yvvy  lari;c  animini  <if  i-cnal  t'])irlielia  thrown 
oii",  it  suggests  some  DWcJuDilcdl  irritation  of  the  kidney  or  its  ])elvis.  If,  in 
addition  to  this,  there  are  red  blood  cells  and  considerable  mucus  present  in 
the  urine,  the  probabilities  of  renal  irritation  are  much  increased. 

The  presence  of  albumin  and  hyaline  casts  point  either  to  marked  irritation 
of  the  kidney  or  to  disease.  If  these  casts  are  granular  and  epithelial  as  well 
as  hyaline,  we  have  reason  to  believe  that  a  more  severe  process,  a  nephritis, 
exists.  If  crystals  are  present  in  masses  of  mucus  or  casts,  we  are  led  to  think 
of  the  probabilities  of  stone.  If,  in  addition,  pus  is  detected,  the  indications  are 
that  there  is  an  infection  of  the  pelvis;  and  if  pus  casts  are  also  found,  it  is 
evidence  that  the  parenchyma  is  also  infected. 

An  increased  amount  of  urine,  of  low  specific  gravity,  leads  us  to  think  of 
tuberculosis,  which  the  presence  of  tubercle  bacilli  "would  confirm.  Atypical 
cells,  tumor  fragments  and  the  presence  of  connective  tissue  lead  us  to  think 
of  tumor.  Blood  in  the  urine  in  connection  with  abnormal  renal  products, 
suggests  tumor,  stone,  tuberculosis  or  hemorrhagic  nephritis. 

While  the  urinary  findings  in  a  large  percentage  of  kidney  cases  give  us  the 
most  reliable  data-  upon  which  to  base  a  correct  diagiiosis,  they  are  frequently 
but  the  first  incentive  to  the  thorough  investigation  of  the  case  and  only  acquire 
a  definite  significance  when  considered  in  connection  with  the  results  of  other 
methods  of  examination. 

We  will  assume  that,  from  the  urinary  findings,  we  have  decided  on  the 
presence  of  kidney  disease  of  a  surgical  nature  and  are  now  desirous  of  locating 
the  trouble.  To  confirm  the  diagnosis  thoroughly,  a  further  examination  should 
include  the  following  steps  in  the  order  given : 

No.  2 :  In  which  kidney  is  the  disease  located  ?  Is  there  another  kidney,  and 
if  so,  is  it  normal  or  abnormal  ? 

External  physical  examination,  including: 

(a)    Inspection,  palpation  and  percussion. 

(&)   Cystoscopy. 

(c)   Ureteral  catheterization. 

No.  3:  What  is  the  nature  of  the  disease  ? 
(a)   Radiography. 
(&)   Guinea-pig  inoculation. 

No.  Jf. :  What  is  the  function  of  the  diseased  kidney  and  its  mate  ? 

(a)  Cryoscopy. 

(b)  Injections  of  methylene  blue. 

(c)  Phloridzin  injections. 

No.  5:  Is  an  exploratory  incision  necessary? 


EXTERNAL   PHYSICAL    EXAMINATTOX  371 

No.  2:  In  which  Kidney  is  the  disease  located?  Is  there  another  kidney, 
and  if  so,  is  it  secreting-?    If  it  is  secreting  is  the  urine  normal  or  abnormal? 

(a)   Inspection,  Palpation  and  Percussion. 

Inspection  sometimes  shows  a  bulging  in  the  loins  and  recalls  to  our  luiiids 
the  possibility  of  hydronephrosis,  pyonephrosis,  tumor  of  the  kidney,  perinephri- 
tie  abscess,  or  rupture  of  the  kidney.  A  bulging  on  one  side  of  the  uiuhilicus 
would  point  to  a  movable  kidney.  Very  little,  however,  is  learned  by  in- 
s])ection. 

Palpation  is,  on  the  other  hand,  a  most  important  method  of  examinatiou, 
as  by  this  means  we  notice  undue  mobility  in  movable  kidney,  and  enlargement 
when  tumor,  hydronephrosis,  pyonephrosis,  pyelo-nepliritis,  perinephritic  abscess 
or  a  cyst  is  present.  By  palpation,  tenderness  is  also  discerned,  indicating  a 
congestion  of  the  kidney,  or  inflammation,  as  pyelitis,  pyelo-nephritis  and  pyo- 
ne]ihrosis.  A  normal  kidney  in  its  normal  position  cannot  be  felt  through  the 
abdominal  wall. 

Methods  of  Palpating  the  Kidney. — The  kidney  is  usually  palpated  in  one 
of  three  ways :  With  the  patient  lying  on  the  back  with  the  knees  flexed ;  in  a 
sitting  posture;  or  lying  on  the  healthy  side.  (See  chapter  on  Examination  of 
Patients,  Figs.  233,  234  and  235.) 

Palpation  with  one  hand  will  sometimes  show  us  a  movable  kidney  or  one 
that  is  enlarged.  The  bimanual  method  is,  however,  the  most  practical  and 
gives  us  a  better  idea  of  its  size,  consistence,  mobility  and  the  presence  or  ab- 
sence of  renal  tenderness. 

When  the  patient  is  examined  lying  flat  on  the  back  with  the  knees  flexed, 
the  examiner  stands  on  the  side  to  be  explored,  facing  the  patient.  If  the  right 
side  is  to  be  examined,  the  right  hand  is  on  the  front  of  the  abdomen  on  the 
outer  side  of  the  rectus  abdominis  muscle  and  the  left  hand  is  on  the  outer  side 
of  the  erector  spina?,  just  below  the  twelfth  rib. 

The  patient  is  directed  to  inspire  and  expire  deeply  and,  during  the  moment 
of  relaxation  when  the  patient  is  breathing  out,  the  hand  on  the  abdomen  pushes 
fli'udy  toward  the  posterior  abdominal  wall,  in  an  effort  to  reach  the  hand  that 
is  ])laced  posteriorly.  The  part  of  the  hand  used  in  examining  is  the  palmar 
surface  of  the  finger  tips.  If  any  surgical  condition  of  the  kidney  is  present, 
a  sensitiveness  is  evident,  while  the  normal  kidney  is  not  tender  to  the  touch. 
Movable  organs  can  be  felt  to  glide  from  under  the  finger  tips  and  can  usually 
be  held  by  anterior  pressure  above  them  and  paljiated  vliolly  or  in  jiart.  (See 
Fig.  233.) 

Ballottemenf  of  the  kiduey  is  the  pushing  of  the  organ  from  the  finger  tips 
of  one  hand  to  those  of  the  other,  and  vice  versa,  by  a  series  of  jars  or  by  gentle 
liiuumual  ])alpation.  By  this  means,  an  enlarged  organ  is  distinctly  felt  and 
can  be  outlined  and  any  tenderness  noticed. 

The  lateral  method  of  palpation  consists  of  placing  the  patient  on  the  healthy 


372  METHODS    OF   EXAMINIA'G   THE   KIDNEY 

side  witli  the  tliiiilis  aiitillcxcd  iiiid  llic  cxiiiiiiiicr  stiiiidiiiu'  Ix-liiinl  the  jjaticnt's 
back.  ]u  cxaiiiiiiiiig'  the  riiiiit  kidney,  the  riiihl  liaiid  is  placed  on  the  front  of 
the  abdomen  and  the  left  behind,  the  same  as  when  examining  a  ])atient  who  is 
placed  in  the  dorsal  position.  The  left  hand  is  often  removed  from  behind  and 
placed  in  front  jnst  below  the  free  border  of  the  ribs,  as  in  cases  of  movable 
kidney.  Pressnre  made  at  this  ])()iiit  in  front,  snlHciciitly  dec])  1o  jirevcnt  llu; 
oi'i;an  from  retnrning  to  its  fossa,  will  allow  the  cxaiuincr  to  oiilline  it  more 
easily  with  the  right  hand. 

The  organ  is  often  palpated  in  tliis  manner  with  greater  accnracy,  and  its 
size,  consistence  and  the  character  of  its  snrface  better  determined.  Kidneys 
are  not  so  easily  mistaken  for  the  liver  by  this  means,  as  we  do  n<it  have  to  ex- 
amine over  the  edge  of  the  latter  organ.     (See  Fig.  23.5.) 

The  kidney  can  often  be  more  easily  felt  in  the  sitting  ])ostiire  tlian  wlu^n 
the  patient  is  lying  down,  especially  in  the  case  of  movable  kidney.  The  hands 
shonld  be  in  the  same  position  in  relation  to  the  patient  when  the  examination 
is  made  in  the  sitting  postnre  as  when  it  is  made  lyiiig  on  tin-  back.  (See 
Fig.  234.) 

I  think  that,  in  palpating  the  kidney,  any  position  or  method  shonld  be 
nsed  which  best  enables  the  examiner  to  accomplish  his  pnrpose.  I  always  ex- 
amine the  patient  on  a  chair-table  and  change  the  position  of  the  patient  while 
making  the  examination  from  the  sitting  to  the  horizontal  position.  When 
there  is  a  movable  kidney,  the  organ  often  drops  down  when  the  patient  is  in 
the  sitting  postnre ;  or  else  it  can  be  made  to  drop  by  having  the  patient  congh 
or  by  jostling  that  region.  In  snch  a  case,  if  pressnre  is  made  by  one  hand  jnst 
below  the  ribs  in  front,  and  the  back  of  the  table  is  lowered  while  the  patient 
is  perfectly  relaxed,  the  organ  is  prevented  from  slipping  back  into  its  fossa 
again  and  can  be  easily  ontlined  hy  the  other  hand. 

The  standing  position,  with  the  patient  resting  the  hnttocks  against  a  table 
or  chair,  will  often  enable  ns  to  palpate  the  organ  in  a  satisfactory  manner. 

Percussion  is  of  valne  in  a  negative  way,  as  tympanitic  resonance  over  the 
anterior  snrface  of  an  abdominal  tnmor  sitnatcd  in  the  loin,  when  the  patient 
is  in  a  dorsal  position,  points  to  its  renal  origin,  on  account  of  the  intestine 
being  placed  in  front  of  it.  Sometimes,  if  there  is  a  dullness  over  a  tnmor  in 
the  loin  by  anterior  percussion,  when  the  patient  is  in  the  dorsal  position,  it  is 
an  advantage  to  inject  gas  into  the  colon  in  order  to  bring  out  the  relatinn  be- 
tween it  and  the  tumor ;  for,  if  it  then  becomes  tympanitic,  it  will  shftw  that 
the  tuinor  is  behind  the  colon  and  therefore,  probably,  renal. 

Liver  dullness  is  not  affected  by  gas  in  the  intestine,  while  the  kidney  dull- 
ness is  obliterated. 

The  routine  examination  of  the  patient  tends  to  clear  up,  to  a  considerable 
degree,  the  question  of  whether  the  kidneys  are  alone  involved  or  not,  in  eases 
in  which  this  has  not  already  been  done.     The  patient  passes  urine  into  a  tube. 


CYSTOSCOPY;    URETEEAL   CATHETERIZATION  373 

and,  if  tlio  urine  is  clear  and  contains  no  shrc<ls,  it  shows  that  tliero  is  no  sup- 
purative involvement  of  tlic  urctlira  or  tlie  ti'act  above  it. 

If  tlie  first  urine  is  turbid  and  tlie  second  is  clear,  it  shows  that  the  turbidity 
is  due  to  sonic  trouble  in  the  urethra,  the  prostate  or  vesicles  tliat  empty  into  it, 
while  the  clear  second  urine  shows  that  there  is  no  marked  suppuration  in  the 
bladder  or  kidney. 

If  both  the  first  and  second  urines  are  turbid  and  the  first  contains  shreds 
while  the  second  does  not,  it  shows  that  the  urethra  is  inflamed  and  that  the 
bladder  or  kidneys  are  also  involved,  unless  the  turbidity  is  due  to  phosphates 
or  bacteria.  When  there  are  such  results,  therefore,  the  urines  should  be 
examined  for  phosphates  or  bacteria  (see  chapter  on  Urinary  Exandna- 
tion ) ,  as  well  as  for  pus  and  inflammatory  products  from  the  bladder  and 
kidneys. 

The  physical  examination  just  made  has,  perhaps,  given  us  some  idea  as  to 
whether  one  or  both  kidneys  are  involved  and  has  brought  us  one  step  further 
forward  in  our  systematic  examination  of  that  organ.  The  patient's  urethra 
should  then  be  examined  for  strictures  and  his  prostate  for  enlargement,  as  all 
obstructions  favor  the  development  of  cystitis  and  suppurative  diseases  of  the 
kidney.  The  patient's  bladder  should  now  be  washed  out,  filled  and  the  cys- 
toscope  introduced. 

(6)  CYSTOscorv. — When  the  fluid  medium  is  clear,  as  is  shown  by  exam- 
ining the  washings  from  the  bladder  in  a  glass  held  before  the  light,  the  in- 
terior of  the  organ  is  examined  with  the  cystoscope.  If  there  is  no  tumor, 
stone,  tuberculosis,  ulceration  or  inflammation  present,  the  bladder  is  known 
to  be  healthy  and  the  mouths  of  the  ureters  should  be  examined  to  see  if  both 
are  present.  In  case  both  ureteral  mouths  are  seen  and  clear  urine  comes  from 
each,  we  knoAv  that  both  organs  are  present  and  that  the  kidney  trouble  is  either 
ase2)tic  or  but  slightly  septic.  If  there  is  an  aseptic  disease  of  one  or  l)oth  kid- 
neys, the  fluid  in  the  bladder  will  remain  clear.  If  the  fluid  quickly  becomes 
opaque,  it  is  a  sign  that  pus  is  coming  from  the  kidney ;  or  pus  flocculi  or  blood 
mav  be  seen  comins'  from  the  mouth  of  one  of  the  ureters  and  not  the  other, 
showing  that  there  is  a  disease  in  the  kidney  from  which  the  abnornuil  products 
come. 

(c)  Uketeral  Catheterization. — If  the  urinary  examination  has  shown 
pathological  renal  findings  of  an  aseptic  nature  and  the  cystoscope  has  show-n 
clear  urine  coming  from  each  kidney,  the  ureters  should  be  catheterized  to 
obtain  a  specimen  from  either  kidney,  in  order  to  discover  which  kidney  is  send- 
ing forth  the  pathological  products  that  Avere  noticed  in  the  general  urinary 
examination,  and,  in  case  both  contain  sucli  findings,  to  ascertain  the  degree  of 
the  involvement  in  each  specimen.  The  passing  of  the  ureteral  catheters  will 
also  tell  if  the  ureter  is  of  normal  size  up  to  the  renal  pelvis  and,  if  not,  the 
nature  and  location  of  the  obstruction. 


374  METHODS    OF   EXAMINING    THE    KIDNEY 

If  Olio  ureter  is  not  seen  tn  exerete,  we  become  siis])icioiis  as  to  the  preseiieo 
of  the  kidney  on  that  side,  and,  if  on  catheterizing  the  ureter  we  find  it  goes 
into  the  renal  pelvis  and  nothing  comes  away,  we  snspect  a  nonfunetionating 
kidney.  If  the  ureteral  catheter  goes  np  but  a  slight  distance  and  no  urine 
conies  through  it,  we  do  not  know  whether  there  is  an  obstruction  of  the  ureter 
on  that  side  that  has  caused  an  atrophy  of  the  organ,  or  whether  there  is  a  con- 
genital absence  of  the  kidney.  In  either  case,  the  patient  would,  of  course,  have 
but  a  single  working  kidney.  In  case  a  turbid  and  flocculent  urine  is  seen  com- 
ing from  one  kidney  while  that  from  the  other  organ  is  clear,  specimens  of  each 
should  be  taken,  and  after  examination  the  result  should  be  compared  with  that 
of  the  general  urine.  The  same  test  applies  to  purulent  urine  coining  from 
both  sides. 

In  case  both  ureters  are  seen  to  be  secreting  urine  and  yet  one  ureter 
cannot  be  catheterized,  the  catheter  should  be  left  in  the  permeable  ure- 
ter, and  an  ordinary  small  soft-rubber  catheter  should  be  passed  into  the 
bladder ;  after  emptying  it,  the  rubber  catheter  should  be  retained  in  order 
to  collect  the  specimen  coming  from  the  ureter  that  could  not  be  cathe- 
terized. 

If  the  bladder  has  been  found,  during  our  cystoscopic  examination,  to  be 
diseased,  we  should  note  this  condition  and  also  the  presence  or  absence  of 
urethral  stricture,  hypertrophied  prostate,  vesical  calculus,  tuberculosis  or 
tumor,  all  of  which  are  guides  to  the  diagnosis  of  diseases  of  the  kidney.  Small 
ulcers  grouped  about  the  mouth  of  one  ureter  point  to  a  tubercular  kidney  on 
that  side. 

It  may  be  here  stated  that  suppurative  disease  of  the  kidney,  when  due  to 
some  cause  not  situated  in  that  organ  or  its  pelvis,  is  more  frequently  secondary 
to  urethral  stricture,  hypertrophy  of  the  prostate,  or  vesical  calculus  than  to 
any  other  causes. 

By  the  means  just  outlined,  we  will  be  able  to  discover  the  presence  of 
urethral,  bladder,  ureteral  or  renal  diseases,  and  to  know  which  of  these  four 
points  of  the  urinary  tract  is  involved  ;  or  whether  two  or  more  are  affected  ;  and, 
if  the  disease  is  renal,  to  know  which  side  is  involved  and  to  form  a  fair  idea 
of  the  condition  of  the  other  organ.  We  can  also  judge  in  a  case  of  renal  dis- 
ease, whether  or  not  the  trouble  is  due  to  lesions  situated  lower  down  in  the 
urinary  tract,  as  oljstructions  or  other  troubles  in  the  urethra,  prostate,  bladder 
or  ureters.  The  comparison  of  the  specimen  obtained  from  each  ureter  with 
that  of  the  general  specimen  from  both  kidneys,  together  wdth  the  general  and 
special  examinations  already  outlined,  will  probably  tell  at  this  time  what  the 
condition  of  each  kidney  is  and  the  nature  of  the  disease.  Single  (unilateral) 
kidneys  and  nonfunetionating  kidneys  are  very  rare.  There  are,  however,  cer- 
tain tests  still  to  be  used,  the  positive  results  of  which  are  confirmative  of  our 
present  conclusions. 


THE    NATURE    OF    THE   RENAL   DISEASE  375 

No.  3:  The  Nature  of  the  Renal  Disease, 

(a)  Radiography. — If  there  lias  been  a  pain  in  the  renal  region  011  one 
side,  if  hematuria  has  followed  the  pain,  if  the  kidney  lias  been  found  to  Ije 
tender  or  enlarged,  if  crystals  have  been  found  in  the  urine  in  masses  of  mucus 
and  epithelia,  we  suspect  a  case  of  aseptic  nephrolithiasis.  If  there  is  a  large 
kidney  on  one  side  that  is  painful  and  tender  with  the  same  findings  that  have 
been  mentioned  above  plus  attacks  of  fever,  pus  and  granular,  epithelial  and 
])us  casts  in  the  urine,  we  must  look  for  a  case  of  septic  nephrolithiasis.  The 
suspicion  of  renal  calculus  becomes  a  probable  diagnosis  if  no  obstructions  to 
the  urinary  flow  have  been  discovered  in  the  urethra  or  prostate,  nor  any  tubercle 
bacilli  or  tumor  fraginents  have  been  found  in  the  urine.  We,  therefore,  proceed 
to  radiograph  the  patient. 

Radiography  should  always  be  resorted  to  when  there  is  the  slightest  sus- 
picion of  stone  and  also  in  all  pus  cases  for  which  there  is  no  appreciable  cause. 
Stones  cannot  always  be  detected  by  radiography,  even  by  the  most  improved 
technique;  but  in  a  large  proportion  of  cases,  the  shadows  have  been  success- 
fully detected  and  a  positive  diagnosis  of  calculus  in  the  kidney  or  ureter  is  gen- 
erally conclusive  by  the  X-ray. 

The  difficulties  to  be  surmounted  in  this  work  are  not  only  the  imperfections 
of  the  apparatus,  excessive  fat  in  the  patient,  accumulation  of  feces  in  the  bowel, 
malformations  of  the  kidney  and  very  small  stones  located  in  the  renal  tissues ; 
but  also  the  permeability  of  renal  stones  to  the  X-rays,  which  is  sometimes  so 
great  that  they  throw  but  a  faint  shadow.  This  is  especially  so  in  cases  of  uric- 
acid  calculi,  the  most  common  kind.  Stones  of  oxalate  of  lime  and  phosphates 
usually  throw  a  shadow  and  even  small  amounts  of  calcium  oxalate  will  throw 
excellent  shadows. 

If  the  picture  is  of  good  quality  and  if  successive  pictures  taken  at  inter- 
vals of  a  fcAv  days  indicate  the  presence  of  stone,  the  surgeon  is  able  to  make  a 
positive  diagnosis.  The  radiographist  should,  however,  be  able  to  take  pictures 
of  a  proper  quality,  and  also  to  interpret  them  correctly.  At  least  two  pictures, 
showing  good  shadows  of  stone,  should  be  obtained,  before  a  positive  diagnosis 
is  made  for  the  purpose  of  operation, 

Lester  Leonard,  of  Philadelphia,  and  Caldwell  and  Cole,  of  Xew  York,  have, 
by  their  extremely  good  work,  been  able  to  obtain  positive  findings  in  nearly  all 
cases  in  which  calculus  was  found  to  be  present  on  operation.  Kummel,  of  Ham- 
burg, has  been  exceptionally  fortunate  in  his  X-ray  work  and  has  concluded 
that  every  stone  in  the  kidney  can  be  detected  by  a  good  X-ray  plate,  of  whatever 
composition  the  calculus  may  be. 

The  important  points  in  obtaining  satisfactory  results  is  to  have  proper 
plates  and  the  requisite  technique.  In  the  first  place,  the  bowels  of  the  patient 
should  be  thoroughly  emptied,  so  that  there  can  be  no  fecal  accumulation  in  the 
colon  over  the  kidney.     Calomel  should  be  taken  the  night  before,  a  saline  laxa-r 


376  METHODS    OF   EXAMINING   THE   KIDKEY 

tive  ill  the  morning  and  a  high  cleansing  enema  after  the  bowels  have  moved, 
after  which  the  picture  should  be  taken.  The  patient  should  be  placed  in  the 
correct  position  and  sulnnitted  to  the  proper  exposure. 

The  shadows  usually  lie  from  four  to  ten  centimeters  to  one  side  of  the  mid- 
dle vertebral  line,  in  a  location  corresponding  to  the  second  lumbar  vertebra,  at 
which  point  the  pelvis  of  the  kidney  is  usually  situated. 

The  patient  is  placed  in  the  dorsal  position,  the  knees  and  thighs  flexed, 
and  an  adjustable  tube  of  medium  softness  is  used  at  a  distance  of  15  cm.  (6 
inches)  from  the  abdominal  wall.  The  abdomen  is  covered  with  a  red  screen, 
limiting  the  area  exposed  ,to  that  of  the  renal  region.  A  photographic  plate 
is  placed  under  the  patient's  back,  corresponding  to  the  opening  in  the 
screen.  The  exposure  should  be  short — about  one  or  two  minutes.  A  shadow 
over  the  suspected  kidney  usually  makes  the  diagnosis  of  nephrolithiasis 
certain. 

(6)  Guinea-pig  Inoculations. — In  the  case  of  a  patient  with  pain,  an 
enlarged  tender  kidney  on  one  side  (and  polyuria  and  frequency  of  urination), 
in  whose  urine  no  tumor  fragments  are  found  coming  from  that  side  and  no 
shadow  is  seen  on  radiography,  tuberculosis  of  the  kidney  is  suspected,  espe- 
cially if  the  individual  is  losing  weight  and  strength.  If  tubercle  bacilli  are 
found  in  the  urine  coining  from  the  suspected  kidney  of  this  patient,  the  diag- 
nosis is  confirmed ;  but  in  case  the  urine  from  that  kidney  does  not  show  tubercle 
bacilli,  it  should  be  at  the  same  time  injected  into  guinea  pigs.  In  fact,  the 
urine  from  both  kidneys  should  be  examined  for  tubercle  bacilli  and  injected 
into  guinea  pigs. 

Guinea-pig  inoculations  are  just  as  importaiit  in  renal  examinations  in  cases 
in  -which  tuberculosis  of  the  kidney  is  suspected,  as  is  the  X-ray  in  cases  in 
which  nephrolithiasis  is  suspected.  The  details  of  guinea-pig  inoculations  have 
been  described  in  a  chapter  on  Tuberculosis  of  the  Kidney,  and  also  in  the 
chapter  on  Examination  of  the  Urine  to  which  the  reader  is  referred.  The 
positive  findings  in  guinea-pig  inoculation  are,  to-day,  an  indisputable  proof  of 
the  presence  of  tuberculosis  in  a  kidney. 

In  other  cases  in  which  the  kidney  on  one  side  is  enlarged  and  the  patient 
has  marked  attacks  of  hematuria,  tumor  of  the  kidney  is  suspected.  If  after 
examining  the  urine  from  the  affected  side  in  such  a  case,  crystals  and  tubercle 
bacilli  are  not  found  and  guinea-pig  inoculations  and  radiography  are  negative, 
tumor  of  the  kidney  is  probably  present,  and  this  diagnosis  would  be  confirmed 
by  the  finding  of  atypical  cells  and  tumor  fragments  in  the  urine  from  that 
kidney. 

The  examination  thus  far  has  shown  how  we  have  arrived  at  the  conclusion 
that  a  kidney  is  diseased,  which  kidney  it  is,  the  nature  of  the  disease,  the  con- 
dition of  the  other  kidney ;  and  it  now^  remains  to  test  the  function  of  the  two 
organs  and  to  determine  their  secreting  power. 


FUNCTIONAL   CAPACITY   OF    TPIE    KIDNEYS  377 

No.  4:  Functional  Capacity  of  the  Kidneys. — The  capacity  for  work,  or 
the  functional  efficiency  of  an  organ,  is  an  index  to  its  health  from  a  physio- 
logical point  of  view.  An  organ  may  be,  to  a  certain  extent,  diseased  and  yet 
able  to  perform  its  function  satisfactorily.  The  functional  efficiency,  or  inef- 
ficiency of  an  organ,  may  or  may  not  be  proportionate  to  the  anatomical  lesions. 
It  is  important  to  know  "vvhat  lesions  are  present  in  the  kidney  and  still  more 
so  to  know  the  amount  of  functional  efficiency  left  in  the  diseased  kidney,  as 
well  as  in  the  organ  of  the  opposite  side. 

It  is  said  that  a  patient  can  live  with  a  third  of  the  total  amount  of  func- 
tionating renal  tissue  normally  present  in  both  kidneys,  but  that  if  there  is 
only  one  fourth  of  the  total  functionating  renal  tissue  left,  he  will  die.  It  is  safer 
to  have  a  remaining  healthy  kidney  that  contains  one  half  of  the  total  amount 
of  the  nornuil  kidney  tissue  of  both  kidneys  than  one  that  contains  but  one  third  ; 
but  it  is  also  safer  to  have  a  remaining  kidney  with  one  third  of  the  total  amount 
of  renal  tissue  than  one  with  but  one  fourth,  as,  in  the  last  case,  there  would 
be  a  renal  insufficiency  that  would  be  fatal. 

By  a  nephrectomy,  we  remove  the  diseased  kidney  tissue,  so  that  the  re- 
nuiining  kidney  is  relieved  of  the  reflex  and  toxic  influences  that  the  organ  has 
had  upon  it.  The  function  of  the  remaining  kidney  improves  and  it  shows 
itself  adequate  to  the  needs  of  the  individual. 

In  surgical  affections,  the  comparison  of  the  functional  state  of  one  kidney 
wdth  that  of  the  other  is  of  paramount  importance.  The  removal  of  one  kidney 
which  may  be  functionally  useless  as  the  result  of  a  tumor,  tuberculosis,  etc., 
is  not  a  dangerous  procedure  if  the  remaining  kidney  is  perfectly  healthy,  as  it 
will  then  be  able  to  take  care  of  the  work  of  both.  If  the  opposite  kidney  is  the 
seat  of  either  the  same  or  of  other  disease,  the  removal  of  the  diseased  organ  is 
contraindicated.  Occasionally,  how^ever,  the  disease  in  the  less  affected  organ 
is  so  slight  that  its  functional  power  is  sufficient  to  carry  on  successfully  the 
elimination  of  the  total  urine  after  the  removal  of  the  more  diseased  one.  Mod- 
ern surgeons  for  this  reason  avoid  the  removal  of  any  kidney  unless  the  func- 
tional examination  of  the  other  organ  shows  it  to  be  sufficiently  healthy.  To  a 
certain  degree,  a  clew  to  the  pathological  lesions  and  to  the  amount  of  work 
a  kidney  can  do  is  obtained  by  the  chemical  and  microscopical  examination  of 
the  urine.  Yet  this  examination  is  not  always  sufficient,  even  wdien  the  urine 
from  each  kidney  is  tested  separately  to  determine  the  condition  of  each  organ. 

Estimating  Renal  Function  in  Surgical  Diseases  of  the  Kidney. — 
In  order  to  determine  the  functional  capacity  of  the  kidneys,  a  twenty-four- 
hour  specimen  should  be  examined.  This  will  tell  us  the  amount  of  liquid 
and  the  amount  of  solid  passed.  The  most  important  solid  is  urea  and,  there- 
fore, this  should  be  taken  principally  into  consideration. 

Knowing  the  normal  amount  of  fluid  passed  in  twenty-four  hours,  as  well 
as  the  amount  of  solid  the  urine  contains,  it  will  be  easy  to  compare  the  total 


378  METHODS    OF    EXAMIXIXG    THE    KIDNEY 

iiriuc  from  the  j)atieiit  Avith  the  normal,  as  avcII  as  the  total  amount  of  urea 
passed.  Low  specilic  gravity  does  not  mean  much,  if  the  auiount  of  solid  is 
sufficient  in  a  twenty-four-hour  specimen,  as  a  diseased  kidney  will  often  give 
off  more  fluid  than  a  healthy  one,  and  nervous  individuals  with  healthy  kidneys 
may  also  have  polyuria.  The  amount  of  urea  in  a  catheterized  specimen  from 
each  ureter,  if  the  catheters  are  allowed  to  remain  in  twenty-four  hours,  com- 
pared with  the  general  twenty-four-hour  connnon  sjjecimen  of  voided  urine, 
would  give  ns  a  good  idea  of  the  amount  of  urine  and  urea  secreted  from  each 
kidney,  and  whether,  in  case  the  diseased  kidney  were  removed,  the  remaining 
organ  could  carry  out  satisfactorily  the  renal  function  of  elimination.  Gener- 
ally, however,  the  catheters  are  left  in  but  one  hour  and  an  estimate  is  made 
between  the  amount  secreted  in  this  time  and  that  passed  in  twenty-four  hours. 

The  Comparative  Flow  of  Ukixe  through  the  Ureteral  Catheters 
IjN^  Examinia^g  the  Kid^teys. — It  is  important,  while  the  catheters  are  in  the 
ureters,  to  note  the  rapidity  and  amount  of  the  urine  coming  from  each  organ. 
A  normal  kidney  secretes  about  an  ounce  an  hour  and  the  urine  flows  in  a 
rhythmical  manner.  If,  on  introducing  a  ureteral  catheter,  an  ounce  or  more 
urine  quickly  escaj^es,  it  shows  a  dilatation  of  the  pelvis  and  renal  retention, 
occurring  either  in  uronephrosis  or  pyonephrosis.  The  turbid  urine  may  be 
white  in  color,  milky,  or  it  may  have  a  yellowish  tinge.  When  white,  there  is 
but  a  small  amount  of  solid  present,  when  darker  a  more  concentrated  urine. 
The  very  light  colored  urine  occurs  in  cases  of  pyonephrosis  in  which  the  kidney 
parenchyma  has  been  almost  entirely  destroyed.  Sometimes  nothing  but  very 
thick  jDus  conies  from  the  ureter  and  slowdy  drops  from  the  end  of  the  ureteral 
catheter,  showing  that  the  kidney  parenchyma  is  practically  destroyed,  that 
the  pelvis  is  not  much  enlarged  and  the  kidney  is  secreting  but  little  or  no  fluid. 

Sometimes  a  diminished  amount  of  turbid  amber  or  yellow  urine  comes  from 
one  kidney  and  an  increased  amount  of  turbid  white  urine  from  the  other.  In 
this  case,  both  kidneys  are  diseased,  probably  the  first  with  pyelitis  or  pyelo- 
nephritis and  the  second  with  pyonephrosis.  The  kidney  secreting  the  turbid 
darker  urine,  w^ould  probalily  he  the  more  acutely  involved  of  the  two,  but  w^ould 
contain  more  functionating  renal  tissue.  In  such  a  case,  the  general  urine 
coming  from  both  kidneys  might  be  the  color  of  lemonade.  A  general  urine 
might  also  resemble  lemonade  when  normal  urine  is  coming  from  one  kidney 
and  a  white  turbid  urine  from  the  other.  Again,  a  general  urine  may  have  a 
lemonade  color  in  case  one  kidney  is  the  seat  of  parenchymatous  nephritis,  and 
the  other  kidney  almost  destroyed  by  pyelo-nephritis  or  pyonephrosis.  On  the 
other  hand,  one  kidney  may  secrete  a  larger  amount  of  urine  of  a  very  low 
specific  gravity,  and  the  other  a  turbid-colored  urine  of  a  higher  specific  gravity. 

These  variations  of  the  balance  of  health  and  disease  in  the  kidney,  as  shown 
by  the  urine,  are  more  likely  to  occur  in  tubercular  affections  of  the  kidney 
than  in  anv  other.     In  determinino'  the  renal  function  of  the  two  kidnevs,  it  is 


FUNCTIONAL    CAPACITY    OF    THK    KIDNEYS  379 

iiecessary  to  compare  llie  fiijdiiJii,'s  in  the  urine  from  ont;  kidiicx-  wiili  ilmsc  of 
the  other,  as  well  as  with  the  findings  of  a  specimen  taken  fi'oni  ihe  entire 
twenty-foTir  hours'  output  of  urine. 

(a)  (^RYOscoi'Y. — It  has  been  proved  experimentally  that  the  freezing  ])oint 
of  a  solution  is  lowered  in  proportion  to  the  nund)er  of  molecules  dissolved  iu" 
a  given  volume  of  the  solution,  no  matter  what  the  weight  of  the  individual 
molecules  may  be. 

Therefore,  the  freezing  point  of  the  blood  or  the  urine  indicates  the  nund)er 
of  molecules  dissolved  in  a  given  volume  of  the  sample. 

The  freezing  point  of  normal  urine  varies  between  —  1.3°  and  —  2.2°  C. 
When  the  kidneys  are  diseased,  the  theory  is  that  fewer  molecules  of  solids 
are  excreted  and  so  the  freezing  point  is  higher — that  is,  nearer  to  0°.  A 
freezing  point  in  urine  higher  than  —  1°  C.  is  usually  regarded  as  abnormal. 
When  the  kidneys  are  almost  destroyed  by  disease,  as,  for  example,  shortly 
before  death  from  uremia,  the  freezing  point  is  often  very  nearly  at  0^,  which 
is  the  freezing  point  of  distilled  water.  ( 

Cryoscopy  is,  therefore,  designed  to  give  us  a  means  of  estimating  the  func- 
tional capacity  of  the  kidney. 

Technique. — Sample  of  urine,  twenty-four  hours'. 

Amount  needed,  10  to  15  c.c. 

Apparatus : — Cryoscope,  consisting  essentially  of  a  very  delicate  thermom- 
eter of  a  special  pattern  known  as  Beckmann's.  The  invention  of  this  ther- 
mometer made  the  delicate  measurements  of  temperature  possible  which  are 
now  used  in  chemical  physics. 

The  freezing  of  distilled  water  (zero)  should  always  be  determined  first 
with  such  a  thermometer  and  any  deviation  from  zero  should  be  noted  as  a 
correction. 

The  other  parts  of  the  apparatus  are :  A  test-tube  in  which  the  nrine  is 
placed,  the  thermometer  fitting  into  this  tube  through  a  perforated  rubber 
stopper.  A  wire  or  hard-rubber  stirrer  spiral  is  used  to  mix  the  urine  during 
the  operation.  Outside  of  the  tube  is  the  receptacle  for  the  mixture  of  ice  and 
salt  usually  employed  for  the  freezing  process. 

To  read  the  thermometer,  the  observer  watches  the  mercury  constantly  from 
the  start.  The  mercury  will  suddenly  begin  to  sink  and  then  will  stop  quite 
low  on  the  scale.  Then  it  will  begin  to  fluctuate  rapidly  and  will  rise  to  a 
point  were  it  will  remain  stationary.  .  This  is  the  freezing  point  of  the  urine 
examined.  It  is,  of  course,  very  important  to  wait  for  the  "  superfusion  "  to 
cease,  as  accurate  readings  cannot  otherwise  be  obtained.  By  practicing 
with  distilled  water,  one  can  accustom  oneself  to  bring  a  mixture  of  salt 
and  ice  to  a  fairly  constant  temperature.  This  outside  temperature  should 
be  about  two  degrees  below  zero  and  another  thermometer  may  be  nsed  to 
reaulate  it. 


380  METHODS    OF   EXAMINING   THE   KIDNEY 

The  error  in  reading  should  not  he  over  y§-y-  of  a  degree.  This  is  accu- 
rate enough  for  clinical  purposes. 

Clinical  Applications  of  Cryoscopy. — The  clinical  value  of  the  method  is 
naturally  limited,  owing  to  certain  sources  of  error,  such  as  imperfect  technique 
and  variations  in  the  normal  freezing  jioint,  and  owing  to  complicated  lesions  of 
the  kidney,  such  as  complete  destruction  of  one  part  of  the  kidney  with  corre- 
sjjonding  hypertrophy  of  another  part,  etc. 

The  chief  value  of  cryoscoi')y  lies  in  the  determination  of  the  relative  freez- 
ing point  of  the  urine  of  each  kidney  separately,  obtained  with  the  aid  of  the 
ureteral  catheter. 

Another,  though  less  important  use  of  the  cryoscope  is  in  the  diagnosis  or 
prognosis  of  a  cystitis  or  pyelitis  when  we  wish  to  know  if  the  process  is  ascend- 
ing into  the  kidney. 

Cryoscopy  of  the  Urine  and  the  Blood. — The  freezing  point  of  the  blood 
is  determined  in  the  same  manner  as  that  of  the  urine  and  the  two  tests  are 
used  as  a  check  upon  each  other.  Keranyi  and  others  found  that  normal  blood 
freezes  at  about  -0.56°  C,  a  figure  which  is  remarkably  constant.  When 
the  kidneys  are  diseased  and  do  not  excrete  as  much  effete  material  as  nor- 
mally, an  increased  amount  of  toxic  substances  accumulates  in  the  blood  and 
thus  the  freezing  point  of  the  blood  becomes  lowered.  Abnormal  kidneys,  there- 
fore, produce  a  lowering  of  the  freezing  point  of  the  blood.  It  has  been  found 
that  when  this  point  is  below  —  0.60°  C,  the  kidneys  are  diseased. 

(1)  When  the  freezing  point  of  the  blood  is  normal  and  when  the  freez- 
ing point  of  the  opposite  kidney  is  also  normal,  the  surgeon  can  safely  extirpate 
the  affected  kidney. 

(2)  When  the  freezing  point  of  the  blood  is  normal  and  that  of  the  urine 
of  the  opposite  kidney  does  not  fall  within  normal  limits,  the  surgeon  should 
perform  a  conservative  operation,  such  as  nephrotomy,  instead  of  nephrectomy. 

(3)  When  the  freezing  point  of  both  blood  and  urine  of  the  opposite  kid- 
ney are  abnormal,  the  surgeon  should  perform  even  more  conservative  opera- 
tions (e.  g.,  incisions  of  nephrotic  sacs)  only  under  the  stress  of  dire  necessity. 

(h)  Methylene-blue  Test. — The  object  of  this  test  is  to  determine  the 
rate  of  excretion  of  methylene  blue  through  the  kidneys,  in  order  to  estimate 
the  functional  value  of  these  organs.  The  coloring  matter  is  injected  intra- 
muscularly in  a  five-per-cent  watery  solution.  ISTormally,  the  blue  color  should 
appear  in  the  urine  in  half  an  hour  after  injecting  it.  If  the  appearance  is 
delayed  to  an  hour  and  a  half  or  longer,  the  kidneys  have  a  diminished  per- 
meability. 

While  the  test  is  attractive  theoretically,  it  is,  unfortunately,  unreliable 
tlinically.  One  objection  is,  that  so  long  as  a  small  amount  of  parenchyma 
remains  healthy,  as  is  often  the  case  in  an  extensively  diseased  organ,  enough 
methylene  blue  will  appear  in  the  urine  promptly  after  injection.     It  seems. 


FUNCTIONAL   CAPACITY   OF   THE   KIDNEYS  381 

that  sonu!  kidneys  mny  Iuin'c  a  certain  selective  action  ii|)oii  inciliylciie  Miie, 
even  though  diseased,  and  ihat  they  excrete  the  d.yo  readily,  even  though  they 
may  not  be  cai)able  of  excreting  the  urinary  constituents.  Conversely,  it  has 
been  found  at  tinios  that  the  kidneys  may  act  normally  so  far  as  excreting 
urine   is   concerned,   but  cannot  excrete   methylene   blue  promptly. 

Another  source  of  error  is  the  fact  that  methylene  blue  may  be  reduced  in 
the  tissues  to  a  chromogen  which  is  excreted  as  such,  and  is  converted  again 
into  the  blue  or  greenish  dye  by  boiling  the  urine  with  acetic  acid. 

The  duration  of  the  excretion  of  a  given  dose  of  methylene  blue  is  also  an 
uncertain  index.  The  duration  may  be  shortened,  the  methylene  blue  being 
excreted  more  rapidly  than  normally  in  both  acute  and  chronic  parenchymatous 
nephritis,  while  it  is  lengthened  frequently  in  the  interstitial  form.  The  length- 
ening of  the  ]ieriod  of  excretion  may  also  be  due  to  compensatory  hypertrophy 
of  the  healthy  kidne_y.  In  the  acute  and  chronic  parenchymatous  forms,  as  well 
as  in  amyloid  kidney,  the  excretion  is  not  materially  modified.  While  the  test 
may  be  useful  in  distinguishing  the  side  affected  by  comparing  the  urines  of 
either  kidney,  it  is  hot  a  trustworthy  guide  as  a  general  standard  for  the  func- 
tional value  of  the  kidney. 

Technique  of  the  Test. — One  c.c.  of  a  five-per-cent  solution  of  chemically 
pure  methylene  blue  is  injected  deeply  into  the  buttock.  The  patient  is  directed 
to  empty  the  bladder  every  quarter  of  an  hour  and  the  urine  is  collected  in  sepa- 
rate glasses.  The  time  of  beginning  elimination,  the  duration  and  amount  of 
coloring  matter  excreted  are  noted.  Each  sample  must  be  tested  with  boiling 
acetic  acid,  in  order  to  convert  the  chromogen  that  may  be  present  into  methyl- 
ene blue.  If  the  dye  appears  within'  half  an  hour,  the  kidneys  are  supposed 
to  be  normal.     The  elimination  lasts  normally  from  thirty-five  to  sixty  hours. 

(c)  The  PuLORiDziisr  Test. — This  test  is  based  upon  the  fact  that,  when 
l^hloridzin  is  injected  into  the  circulation,  sugar  is  excreted  by  the  kidney  and 
appears  in  the  urine. 

This  test  is  performed  by  injecting  subcutaneously  1  c.c.  of  a  1 :  200  solu- 
tion, that  is,  5  milligrams  of  the  drug.  The  patient  is  allowed  to  urinate  before 
the  injection  and  his  urine  is  tested  to  see  that  it  contains  no  sugar.  The  urine 
is  then  collected  each  quarter  of  an  hour  and  each  sample  is  tested  for  sugar. 
The  urine  is  cleared  first  by  thorough  filtering. 

Normally,  sugar  appears  within  half  an  hour  to  an  hour,  disappears  within 
three  or  four  hours  and  the  total  amount  excreted  is  from  one  to  two  grams. 
In  chronic  nephritis,  with  interstitial  changes,  the  excretion  is  either  dimin- 
ished or  abolished,  even  when  no  albuminuria  is  present. 

Israel  objects  to  the  phloridzin  test  and  denies  that  the  amount  of  healthy 
parenchyma  is  indicated  by  the  amount  of  sugar  excreted.  But  even  if  the 
glycosuria  is  not  a  measure  of  the  work  of  the  kidney,  Avhen  there  is  a  marked 
difference  in  the  amount  of  sugar  excreted  by  either  kidney,  we  can  determine 


382  METHODS    OF   EXAMINING    THE    Kn)XEY 

-which  of  the  two  works  better.  When  this  (liri'ci'cnce  is  very  inark('(l  with  a 
very  low  amount  of  glucose  on  one  side,  we  arc  justified  in  concluding  that 
this  particular  kidney  is  probably  functionally  insufficient. 

Having  given  the  urine  the  functional  tests,  in  addition  to  the  remainder 
of  the  examination,  we  can  feel  that  everything  has  been  done  that  is  required 
in  order  to  determine  the  condition  of  the  healthy  and  the  unhealthy  kidney, 
exce])ting,  perhaps,  an  ex])loratory  incision. 

No.  5:  Exploratory  Incision. — An  exploratory  incision  is  rarely  necessary. 
There  are,  however,  cases  in  which  we  must  resort  to  it,  on  account  of  an  ex- 
tremely contracted  bladder,  hemorrhagic  cystitis,  sacculated  bladder,  or  such 
an  unusual  amount  of  blood  or  pus  in  the  urine  coming  down  from  the  kidneys 
that  we  cannot  see  the  ureteral  mouths  or  the  urine  coming  from  them. 

Such  difficulties  to  cystoscopy  and  ureteral  catheterization  are  seldom  en- 
countered, but  they  are  occasionally  met  with  in  cases  in  which  there  is  an 
enlargement  of  the  kidney  on  one  side  with  findings  of  renal  disease  in  the 
urine,  and,  besides,  constitutional  symptoms  that  call  for  operative  interference 
in  the  case  of  the  enlarged  organ.  Here  an  exploratory  incision  should  be 
made  on  the  side  of  the  suspected  healthy  kidney  to  examine  it  before  operating 
on  the  suspected  diseased  one. 


CHAPTER    XX 

ANOMALIES  OF  THE  KIDNEY 

Anomalies  of  the  kidney  gland  proper,  and  of  the  renal  blood  vessels, 
are  intimately  linked  embryologically  with  the  anomalies  of  the  ureter.  They 
are  all  congenital  and  explained  by  embryology.  Major  abnormalities  are  rare; 
])ut  minor  anomalies — small  deviations  from  the  normal  type — are,  on  the 
contrary,  rather  common.  The  complexity  of  the  developmental  process  of  the 
upper  urinary  tract,  which  is  very  intricate,  easily  accounts  for  the  frequency 
of  the  minor  defects. 

The  subjects  can  be  treated  here  but  briefly  and,  in  case  our  readers  desire 
further  information,  we  refer  them  to  the  "  Surgical  Diseases  of  the  Kidney 
and  Ureter,"  by  Morris  (London,  vol.  i,  p.  18). 

Some  abnormalities  have  great  surgical  importance,  while  others  have  only 
an  anatomical  and  embryological  interest,  and  represent  transitory  fetal  stages 
which  have  become  accidentally  permanent. 

ANOMALIES    OF   THE   KIDNEY   GLAND   PROPER 

Anomalies  of  the  kidney  gland  proper  may  be  classified  under  four 
headings. 

A.  Anomalies  of  Position. — Congenital  ectopic  kidneys  have  been  found  at 
the  saero-iliac  joint,  which  will  be  shown  later  in  the  chapter  on  Hydronephrosis, 
over  the  promontory  of  the  sacrum,  just  below  the  bifurcation  of  the  aorta,  and 
in  the  false  pelvis  just  above  Poupart's  ligament.  Such  a  kidney  may  be  single 
or,  what  is  more  frequent,  associated  with  another  normally  developed  and 
normally  placed  kidney.  The  vessels  are  short  and  multiple,  and  spring  abnor- 
mally from  neighboring  blood  vessels,  thereby  differentiating  such  a  congen- 
i tally  misplaced  kidney  from  an  ordinary  movable  kidney  secondarily  fixed  by 
adhesions.  The  ectopic  kidney  is  fixed  in  its  position  and  adhesions  may  be 
present,  but  the  origin  of  the  vessels  is  evidence  of  a  congenital  anomaly.  The 
organ  may  be  found  in  any  part  of  the  abdomen,  or  in  the  pelvis,  and  this  is 
usually  associated  with  other  congenital  abnormalities  of  the  genito-urinary 
organs.     It  is  more  common  in  males  than  in  females. 

Kidneys  displaced  into  the  pelvis  may  give  rise  to  distnrliances  of  defeca- 

383 


384  ANOMALIES    OF    THE    KIDNEY 

tion  and  also  of  lu'iiiatioii.  siicli  as  froquciil  mictiirilion  and  tenesmus;  hema- 
turia and  ])ynria  arc  also  seen  in  tlicse  cases.  The  displaced  organs  become  the 
seat  of  hydronephrosis  or  ])yonci)hrosis,  with  symptoms  of  pelvic  or  abdominal 
tnmor.  The  diagnosis  can  be  made  theoretically  by  a  pelvic  examination  per 
vagina  or  ])er  rectnm.  The  introduction  of  a  ureteral  catheter  also  assists,  by 
showing  tliat  the  nreter  a])])ears  short  and  obstructed  ;  but  an  exploratory  lapa- 
rotomy is  necessary  for  a  correct  diagnosis,  as  this  will  allow  us  to  find  the  ab- 
sence of  the  kidney  in  the  renal  fossa,  and  its  presence  in  the  pelvis.  If,  in  a 
woman,  the  organ  is  so  jdaced  as  to  interfere  with  childl)irth,  and  if  the  opjjosite 
kidney  is  not  diseased,  it  is  best  to  remove  the  displaced  gland,  providing  this 
can  be  done  without  too  much  tearing  of  the  surrounding  adherent  structures. 
Cragin  removed  such  a  kidney  by  the  vaginal  route.  Israel,  in  operating  on 
such  a  case,  closed  the  alxlominal  wound  made  for  exploratory  pnrposes  and 
performed  an  extraperitoneal  nephrectomy.  Misplaced  kidneys  are  ectopic. 
Displaced  kidneys  are  movable  kidneys  that  have  fallen  from  the  renal  fossa 
and  become  fixed  where  they  finally  lodged, 

B.  Anomalies  in  Mobility. — These  comprise  the  cases  of  congenital  movable 
kidney.  They  ocenpy  an  intermediary  position  between  an  ectopic  kidney  and 
an  acquired  movable  kidney.  There  are  two  types,  according  to  the  normal 
or  abnormal  origin  of  the  vascular  pedicle,  and  the  length  of  the  latter.  Some- 
times the  kidney,  instead  of  being  held  against  the  posterior  abdominal  wall  by 
the  peritoneum  in  front  of  it,  has  a  true  mesonephron. 

C.  Anomalies  in  Shape. — The  most  frequent  is  lohuJalion.  It  is  due  to  the 
persistence  of  a  transitory  fetal  disposition  and  reproduces  the  type  of  kidney 
normal  in  some  species  of  animals.  The  fissures  may  be  so  deep  as  to  give 
tbe  impression  of  a  multiple  kidney.  According  to  Kiister,  fetal  kidneys  are 
subject  to  tul)erculosis,  and  his  opinion  is  confirmed  by  other  authors.  These 
fissures  will  be  noticed  in  the  illustration  of  single  congenital  unsymmetrical 
Sidney.     (See  Fig.  265.) 

Hour-glass  contraction  occasionally  occurs,  but  it  is  very  rare. 

Sometimes  there  exists  a  fusion  of  two  homologous  poles  of  both  kidneys, 
the  lower  ones  generally,  the  upper  more  rarely.  This  gives  rise  to  a  horse- 
shoe kidney,  two  subvarieties  of  wdiich  are  the  sigmoidal  kidney  and  the 
discoidal,  jdacentalike  kidney. 

Horseshoe  kidney  usually  shows  an  isthmus  and  two  free  ends  which  point 
upward.  Less  frequently,  the  two  ends  point  downward,  the  upper  poles  of 
the  kidney  having  coalesced.  One  of  the  kidneys  may  be  much  larger  than  the 
other,  and  often  the  bridge  or  isthmus  is  composed  merely  of  fi1)rous  tissue.  The 
ureters  are  usually  two  in  number ;  sometimes  four  are  prese.nt,  and  run  across 
the  isthmus  from  above  downward. 

Horseshoe  kidneys  are  usually  displaced  downward  and  toward  the  median 
line,  as  low  as  the  sacral  promontory.     Supernumerary  renal  vessels  often  occur 


ANOMALIES    OF    THE   KIDNEY   GLAND   PROPER  385 

in  these  cases,  and  a  central  renal  artery  may  spring  from  the  aorta  and  snpply 
the  isthmus. 

Clinically,  horseshoe  kidney  is  of  importance  on  account  of  the  possibility 
of  an  operator  inadvertently  removing  the  whole  mass  as  one  kidney.  Partial 
excisions  of  horseshoe  kidneys  have  heen  done  by  Soein,  Kinug  and  others  and 
the  isthmus  has  been  severed  after  ligating  it,  or  the  lieiiiori'hage  has  b(;cn 
stopped  with  the  cautery. 

The  diagnosis  of  a  horseshoe  kidney  is  not  simple,  and  at  best  we  may  sur- 
mise the  presence  of  this  anomaly  when  we  feel  an  abnormal  median  renal 
tumor,  or  see  the  shadows  of  calculi  very  close  to  the  spine.  Sometimes  a  horse- 
shoe kidney  can  be  felt  as  a  pulsating  tumor  over  the  aorta,  over  which  a  sys- 
tolic murmur  is  heard.  Hydronephrosis  sometimes  occurs  in  a  horseshoe 
kidney.     An  exploratory  incision  is  the  only  positive  means  of  diagnosis. 

Both  poles  of  both  kidneys  may  be  fused,  forming  a  variety  known  as  annu- 
lar I'idney,  often  called  solitary  kidney  and  considered  as  a  single  kidney.  This 
we  believe  to  be  unjustified,  as  there  are  two  kidneys  and  two  ureters,  and  this 
anomaly  is  simply  an  exaggeration  of  the  horseshoe  type. 

D.  Anomalies  in  Number. — Cases  of  supernumerary  kidneys  are  few  and 
not  always  well  authenticated.  The  mode  of  development  of  the  ureter  and 
kidney  makes  one  doubtful  as  to  the  possibility  of  supernumerary  kidneys. 

Much  more  important  than  the  anomaly  of  excess  is  the  anomaly  of  default. 
The  absence  of  both  kidneys  is  only  a  teratological  curiosity  of  the  first  months 
of  embryonic  life.  The  absence  of  one  kidney,  either  on  account  of  nonforma- 
tion,  or  of  congenital  atrophy,  is  the  chief  anomaly  of  the  kidney  from  a  surgical 
standpoint. 

Statistics  show  that  single  kidneys  are  very  rare,  although  sometimes  they 
appear  to  be  frequent.  This  is  conclusivelv  shown  by  my  own  experience  with 
the  anomaly. 

During  the  eight  years  that  I  spent  teaching  anatomy  and  operative  surgery 
at  the  Post-Graduate  Medical  School,  with  large  numbers  of  cadavers  always 
in  use,  in  which  both  kidneys  were  dissected  or  operated  upon,  I  failed  to  see 
one  instance  of  single  kidney,  and  this,  together  with  the  same  experience  in 
numerous  autopsies,  led  me  to  believe  that  such  a  condition  almost  never  ex- 
isted;  I  changed  my  opinion,  however,  when  I  encountered  three  single  kid- 
neys in  a  small  hospital  service  within  a  period  of  less  than  ten  months,  during 
which  time  only  fifteen  autopsies  had  been  performed.  This  is  certainly  unus- 
ual, when  Guy's  hospital  reports  say  that  in  4,632  cases,  only  one  congenitally 
single  kidney  was  found  in  a  period  of  ten  years. 

A  single  kidney  nniy  be  associated  with  deformity  of  the  organ  or  another 
form  of  anomaly,  lobulation.  This  point  is  important  to  remendier  when  oper- 
ating, as  when  one  is  not  sure  that  there  is  a  second  kidney,  sus^ncions  may  be 
aroused  by  an  abnormally  large  and  lobnlated  kidney  on  the  side  operated  upon. 


386 


ANOMALIES    OF   THE   KIDNEY 


The  situation  of  a  single  kidney  varies  considerably:  it  may  be  found  in 
the  loin,  or  in  the  median  line,  at  the  brim  of  the  pelvis,  etc.  It  is  usually 
larger  than  normal,  when  in  a  healthy  state,  and  mviy  also  be  enlarged  from 
disease.    It  is  generally  found  on  the  right  side  and  more  commonly  in  men. 

The  renal  vessels  are  usually  absent  on  the  side  where  the  kidney  is  lacking 
and  the  ureter  as  well.  Wankiewicz  collected  statistics  of  234  cases  of  single 
kidney,  showing  rudiments  of  the  ureter  in  17  cases,  absence  of  the  kidney  on 
the  left  side  in  127  cases,  and  on  the  right  side  in  97  cases,  while  in  12  the  side 
was  not  given ;  malformation  of  the  bladder  in  most  of  the  cases ;  no  trace  of  a 
ureteral  orifice  in  the  bladder  on  the  side  where  the  kidney  was  absent  in  74 
cases,  while  in  others  a  small  indentation  or  diverticulum  was  found  where  the 
ureter  should  have  been ;  absence  of  one  half  of  the  trigone  in  some  cases,  and, 
in  others,  termination  of  the  single  ureter  in  the  center  of  the  bladder.  Ac- 
cording to  Wankiewicz,  therefore,  absence  of  a  ureteral  mouth  occurs  in  one 
third  of  the  cases  of  single  kidney  and  may  then  be  detected  by  the  cystoscope. 

A  single  kidney  may  be  excluded  only 
when  both  ureters  can  be  catheterized 
and  are  shaped  to  discharge  urine. 

A  single  kidney  is  interesting  sur- 
gically, because  it  may  become  the  seat 
of  an  affection  demanding  nephrectomy, 
such  as  tuberculosis  or  cancer.  The 
following  case  is  an  example  of  the  kind 
and  carries  out  the  views  of  Kiister  in 
that  it  was  a  lobulated  kidney  of  the 
fetal  type  with  deep  fissures  and  the 
seat  of  tuberculosis.  The  patient  Avas 
on  my  service  at  the  Columbus  Hos- 
pital. 

Case  I. — Laborer,  aged  twenty-one 
years,  was  referred  to  me  for  nephrectomy 
for  tuberculous  kidney.  Incision  in  the 
left  loin  showed  a  large  left  kidney  al- 
most divided  in  halves  by  a  fissure  and 
completely  riddled  with  small  tubercles 
and  abscesses.  I  removed  the  organ  and 
the  patient  died  of  uremia  on  the  eighth 
day  after  nephrectomy.  The  right  kidney  was  found  congenitally  absent,  as 
was  the  suprarenal  capsule  on  that  side.  Fig.  265  shows  the  appearance  of  the 
extirpated  single  kidney.  This  organ  was  5^  inches  long,  3  inches  wide  and  2^ 
inches  thick.  The  kidney  resembled  a  large  ripe  tomato,  only  of  a  deeper  red 
color.     It  was  lobulated,  there  being  four  quite  distinct  lobules.     The  fissures 


Fig.  265. —  Minute  Tubercular  Abscesses 
OF  A  Single  Asymmetrical  Kidney.  Note 
the  deep  fissures  and  convolutions;  it  was 
5  3^2  inches  long  and  very  thick.  (Author's 
case.) 


ANOMALIES    OF    THE    KIDNEY    GLAND    PEOPER  387 

between  these  lobules  did  not  extend  llirougb  the  organ.  The  (jrgan  was  mahog- 
any red  and  studded  with  siiuill  tubercular  abscesses  under  the  capsula  propria, 
varying  in  size  from  a  })in  point  to  a  split  pea.  The  upper  pole  was  larger  and 
more  involved.  The  kitlney  had  much  fat  attached  to  its  capsula  propria ;  there 
was  but  one  pelvis  and  one  ureter  present. 

Microscopical  Examination. — The  kidney  showed  intense  inflammation  and 
numerous  miliary  tubercles  and  abscesses,  degeneration  of  the  epithelia  of  the 
tubules,  little  new  connective  tissue,  periarterial  extravasation  of  leukocytes,  epi- 
thelia of  the  glomeruli  thickened  and  the  tubules  filled  with  casts. 

In  the  place  of  the  right  kidney,  there  was  an  extension  of  the  right  lobe  of 
the  liver  down  to  the  renal  fossa  on  that  side,  resembling  a  tongue,  about  3-^- 
inches  in  length,  3  inches  in  width  at  its  upper  part,  gradually  ending  in  the 
shape  of  a  wedge,  slightly  twisted  on  itself.     No  other  abnormality  was  noticed. 

When  an  affection  developing  in  a  single  kidney  can  be  treated  conserva- 
tively, as  calculus  hydronephrosis  or  pyonephrosis,  the  outlook  is  not  so  gloomy, 
although  if  the  calculus  were  to  obliterate  the  ureter,  complete  anuria  would 
immediately  ensue.  A  single  kidney  may  be  present  in  persons  w^ho  are  in 
perfect  health,  and  an  advanced  age  may  be  reached  with  only  one  kidney ;  but 
it  seems  that  these  kidneys,  despite  their  compensatory  hypertrophy,  are  weaker 
and  more  liable  to  disease  than  ordinary  normal  kidneys.  There  is  said  to  be 
a  tendency  to  albuminuria  in  young  persons  with  a  single  kidney,  and  also  a 
tendency  to  the  formation  of  renal  stones.  Hydro-  and  pyonephrosis  from  un- 
discovered causes,  and  chronic  nephritis,  have  also  been  recorded  in  single  kid- 
neys. It  should  be  noted  that,  in  the  two  following  cases,  the  diseases  from 
which  the  patients  were  suffering  were  in  themselves  sufficient  cause  for  death, 
and  yet  in  both  cases  the  kidneys  were  diseased.  In  these  two  cases,  the  patients 
were  in  the  prime  of  life  and  it  is  not  illogical  to  suppose  that  the  single  kidney 
created  a  physiological  inferiority,  partly  responsible  for  the  fatal  outcome. 

Case  II  (On  the  service  of  Dr.  C.  H.  Lewis,  at  the  Columbus  Hospital). — - 
Fireman,  aged  thirty,  died  of  empyema.  Autoj^sy  revealed  the  presence  of  a 
single  kidney  situated  on  the  left  side.  The  right  kidney  and  ureter  were  absent. 
The  left  kidney  was  in  normal  position,  Y|  inches  long,  4  inches  wide,  2^  inches 
thick ;  it  was  not  distinctly  lobulated,  but  there  were  depressions  upon  it,  giving 
rise  to  irregularities  on  the  external  surface.  The  lower  lobe  was  widi'r  than 
the  u]iper.    Neither  kidney  nor  ureter  was  found  on  the  other  side. 

Microscopical  examination  made  by  Dr.  Noyes  showed  degeneration  of  the 
epithelia  in  the  tubes,  and  casts,  little  new  connective  tissue,  few  red  blood  cor- 
puscles, glomeruli  showed  some  cheesy  exudation  in  capsule  periphery,  con- 
nective-tissue proliferation  (Fig.  2G6). 

Diagnosis.— Acute  parenchymatous  no]diritis. 

Case  III  (Occurred  in  the  Medical  Ward  of  the  Cidundms  Hospital  in  the 
service  of  Dr.  Keller  and  is  ]iul)lished  liv  his  permission). — Laborer,  twenty- 


388 


ANOMALIES    OF    THE   KIDNEY 


five  years  old.  Diagnosis,  typhoid  fever.  Died  at  hospital  in  the  tliird  week 
of  the  disease.  The  autopsy  showed  that  but  one  kidney  was  present,  situated 
on  the  right  side,  somewhat  lobulated,  with  single  pelvis  and  ureter ;  on  the 
left  side,  neither  kidney,  ureter  nor  suprarenal  capsule  was  found.     The  kidney 


Fig.  266.  —  Single  Asymmetrical  Kidney,  7>^ 
Inches  Long,  Removed  at  Autopsy.  Note 
the  fissures  and  depressions.  (Author's  collec- 
tion.) 


Fig.  267. — Single  Asymmetrical  Kidney,  Mark- 
edly Convoluted,  Removed  at  Autopsy. 
(Author's  collection.) 


was  4  inches  long,  2|  inches  wide  and  2  inches  thick.    Five  or  six  irregular  ele- 
vations could  be  seen  on  its  surface. 

The  microscopical  report  of  Dr.  Noyes  showed  changes  of  chronic  inter- 
stitial nephritis,  with  the  production  of  a  moderate  amount  of  new  connective 
tissue,  degeneration  of  tubules  in  the  cortex  with  exudates,  glomeruli  filled  with 
leukocytes,  proliferation  of  epithelia.  The  tubules  in  the  medullary  portion 
were  more  normal  (Fig.  267). 


ANOMALIES   OF   THE   BLOOD   VESSELS 

Vascular  anomalies  may  exist  in  cases  of  abnormal  kidneys,  but  they  may 
also  be  found  in  an  otherwise  perfectly  normal  gland.  Some  of  these  anomalies 
have  a  surgical  interest,  although  most  are  mere  anatomical  curiosities. 

The  vessels  may  be  abnormal  by  their  origin,  by  their  distribution  or  by 
their  number.  Anomalies  of  the  renal  artery  are  more  important,  and  also 
more  common  than  those  of  the  vein. 

The  artery  may  originate  much  lower  than  usual ;  this  is  ordinarily  coupled 


ANOMALIES    OF    THE    BLOOD    VESSELS  389 

with  a  congenital  ectopy  of  the  gland.  Among  the  anomalies  of  distribution,  the 
most  interesting  is  the  premature  branching  off  from  the  trunk  of  the  renal 
artery  of  the  branch  going  to  the  lower  pole  of  the  kidney.  This  artery  then 
crosses  the  ureter  near  its  origin,  and  may  become  the  cause  of  an  hydro- 
ne])hrosis;  in  three  cases  out  of  four  (English),  it  passes  in  front  of  the  ureter, 
whereas  in  the  fourth  it  passes  behind.  This  artery  is  not  a  supernumerary 
vessel,  as  is  sometiriies  stated ;  but  it  is  a  normal  artery  of  the  kidney,  which 
cannot  be  ligated  or  cut  without  necrosis  of  the  corresponding  part  of  the  gland. 

The  renal  artery  itself  may  be  replaced  by  two,  three  or  even  four  trunks. 

There  may  also  be  renal  supernumerary  arteries  that  are  small  and  may 
be  severed  without  interfering  with  the  nourishment  of  the  kidney  but  may 
give  rise  to  considerable  hemorrhage  during  renal  operations. 

An  embryologically  interesting  anomaly  of  the  left  renal  vein  is  that  in 
which,  all  other  things  being  normal,  the  vessel  ends  abnormally  low  into  the 
vena  cava,  at  the  level  of  the  fourth  lumbar  vertebra,  and  receives  perpendicu- 
larly the  vena  azygos  minor. 


CHAPTER    XXI 

KIDNEY  INJURIES 

Broadly  speaking,  there  are  two  varieties  of  kidney  wounds :  First,  those 
that  are  inflicted  without  the  wall  of  the  body  having  been  opened  or  pierced ; 
and  second,  injuries  of  the  organ  by  some  instrnment,  weapon  or  missile  that 
has  passed  through  the  body  wall.  The  former  is  called  a  suhparietal  (closed) 
injury,  and  is  usually  due  to  a  direct  blow,  a  fall,  striking  on  the  kidney  region, 
or  a  crush  from  the  wheel  of  a  vehicle ;  the  latter  is  called  an.  open  wound,  and 
is  due  to  a  slash  or  a  puncture  with  a  knife,  sword  or  bayonet,  or  to  a  pro- 
jectile from  a  firearm. 

Kidney  injuries  are  rare,  if  surgical  wounds  are  excluded.  In  7,741  cases 
of  injuries  reported  by  Kiister,  but  10  were  renal.  Contusions  are  the  most 
frequent,  next  come  gunshot  wounds  and  last  incised  and  punctured  wounds. 
I  have  had  5  cases  of  suhparietal  injury  and  1  open  wound  (a  stab). 

There  is  an  instinctive  tendency  to  consider  all  injuries  involving  the  kid- 
ney as  dangerous.  This  idea  has  been  inherited  from  surgeons  who  were  not 
•familiar  with  renal  surgery,  but  at  the  present  writing  operative  interference 
has  shown  us  that  this  fear  was  not  justified  and  that  kidney  wounds,  like  the 
wounds  of  all  highly  vascular  organs,  often  heal  quickly.  Experimental  sur- 
gery, in  the  hands  of  Albarran,  Legueu,  Paoli,  Podvyssotsky,  Tuifier  and  others, 
has  taught  us  that  the  mechanism  of  wound  repair  in  the  kidney  is  essentially 
the  same  as  in  any  other  parenchymatous  organ ;  that  is,  the  proliferation  of  the 
interstitial  connective  tissue  of  the  gland  bridges  the  gap  between  the  two  edges 
and  then  permanently  replaces  this  temporary  mending  in  the  natural  way  with 
the  aid  of  a  clot.  The  functionating  elements  of  the  gland  degenerate  and  are 
replaced  by  connective  tissue.  Scar  formation  is  rapid  in  the  kidney  and  the 
process  of  repair  has  been  shown  far  advanced  after  six  days.  The  parenchyma 
is  substituted  by  common  scar  tissue,  which  is  slowly  permeated  by  scant,  newly 
formed  capillaries.  It  has  been  claimed  by  several  that,  after  the  healing  of  a 
kidney  injury,  a  regeneration  of  the  epithelial  cells  and  the  glomeruli  takes 
place.  I  do  not  believe,  however,  that  such  a  process  is  possible,  as  in  such  a 
case  the  kidney  parenchyma  would  have  regenerative  powers  that  are  not  shared 
by  other  tissues  in  the  body.  The  epithelial  cells  of  the  kidney  are  so  delicate, 
that  even  a  temporary  ligature  of  the  renal  vein  is  enough  to  alter  them  deeply ; 
390 


SUBPAKIETAL   INJUEIES  391 

and  liig"hl,y  sjieeiali/ed  cells  do  not.  regenerate.  As  for  glomendi,  one  docs  not 
understand  how  sneh  a  complex  formation  could  regenerate,  even  in  very  young 
people.  If  the  glomeruli  appear  more  abundant  near  a  renal  scar,  it  is  prolj- 
ably  because  of  the  shrinkage  of  the  connective  tissue  in  the  vicinity. 

There  is  undoubtedly  a  compensatory  hypertrophy  after  any  loss  of  sub- 
stance of  the  kidney,  but  this  is  not  due  to  the  regeneration  of  renal  elements. 
(\)m])ensation  in  the  remaining  kidney,  after  nephrectomy,  for  instance,  is 
established  not  through  formation  of  new  elements,  but  through  an  increase  in 
size  and  in  functional  activity  of  the  surviving  elements ;  for  it  must  not  be 
overlooked  that  we  have  normally  in  the  body  a  much  greater  amount  of  kidney 
tissue  than  is  necessary  for  the  maintenance  of  life.  Tuffier  removed  one  kid- 
ney in  dogs  and  had  to  slice  off  a  large  part  of  the  other,  before  he  obtained  any 
symptoms  of  urinary  insufficiency. 

SUBPARIETAL   INJURIES 

Etiology. — Contusions  of  the  kidney  are  seen  a  little  more  frequently  on 
the  right  side  than  on  the  left  (142  to  118).  They  sometimes  have  taken  place 
in  both  sides ;  while  cases  are  on  record  of  the  rupture  of  a  single  asymmetrical 
kidney,  and  one  case  of  a  ruptured  horseshoe  kidney.  In  my  series,  3  cases 
were  on  the  right  side.  The  most  susceptible  age  is  from  ten  to  thirty,  that  is, 
the  age  of  greatest  muscular  activity  and  liability  to  accident.  Men  are  much 
oftener  affected  than  women.  In  my  personal  cases,  eighty  per  cent  occurred 
in  men.  Kiister  gives  even  as  high  as  ninety-four  per  cent  in  men  and  six  per 
cent  in  women. 

The  kidney  may  undergo  rupture  as  a  consequence  of  a  direct  violence,  such 
as  a  blow,  fall  on  the  loin,  kick  from  a  horse ;  or  of  an  indirect  compression  of 
the  body  between  two  surfaces,  as  in  elevator-shaft  accidents,  by  the  pinning 
of  the  lumbar  region  between  the  buffers  of  railroad  cars,  or  by  the  passage  of 
a  carriage  wheel  over  the  costo-iliac  space,  the  body  resting  flat  on  the  ground. 
The  latter  two  accidents  and  a  fall  on  the  loin  are  the  most  common. 

Some  claim  that  a  kidney  may  be  ruptured  by  indirect  violence,  such  as  a 
strong  muscular  contraction  when  the  body  is  bent  suddenly  forward  or  on  one 
side;  but  personally  I  am  inclined  to  doubt  the  possibility  of  a  rupture  of  so 
well-protected  and  so  movable  an  organ  from  a  mere  muscular  contractiou, 
unless  the  kidney  is  very  much  congested  or  distended  on  account  of  some  ob- 
struction to  the  urinary  flow. 

The  theories  of  the  mechanism  of  rupture  do  not  accoimt  for  all  forms  of 
renal  injuries,  but  the}^  are  the  best  we  have  at  our  disposal  at  ])resent. 

Pathology. — The  pathology  of  contusions  depends  on  whether  the  fibrous 
capsule  is  torn  through  or  not.  If  the  capsule  is  not  torn  through,  the  hemor- 
rhage is  usually  slight,  in  which  case  there  is  a  subcapsular  ecchymosis  or  hema- 


392  KIDNEY   INJUKIES 

tonia,  or  irrcgnlarly  shaped  areas  of  hemorrhage  within  the  parenchyma  near 
the  surface  or  extending  as  deep  as  the  pelvis. 

True  rupture  exists  when  the  capsule  is  torn  and  the  laceration  is  deep 
enough  to  communicate  with  the  pelvis  of  the  kidney.  Fissures  are  usually 
found  on  the  anterior  aspect  of  the  organ  and  are  transverse  in  direction  or 
radiate  from  the  hilus.  Infarcts  of  the  usual  wedge  shape  may  follow  con- 
tusions of  the  kidney.  In  cases  of  true  rupture  of  the  kidney,  there  is  an  ex- 
tensive leakage  of  blood,  or  blood  and  urine,  into  the  surrounding  tissue,  ac- 
cording to  W'hether  the  excretory  channels  are  torn  or  not.  If  the  rupture  is 
very  extensive,  the  two  halves  of  the  kidney  are  held  together  by  the  pedicle 
only,  or,  in  extreme  cases,  the  kidney  may  be  divided  into  a  number  of  small 
pieces,  some  of  which  may  be  totally  detached. 

The  perirenal  extravasation  may  burrow  down  along  the  ureter  and  collect 
around  the  pelvic  organs,  but  it  usually  collects  in  the  retroperitoneal  cellular 
tissue,  Avhere  it  forms  a  rapidly  growing  liquid  tumor  known  as  a  pseudo- 
traumatic  hydronephrosis.  The  contents  of  the  tumor  resulting  from  rupture 
of  the  kidney  consist  of  a  brown-red  fluid,  which  it  is  said  may  later  change  to 
amber  and  resemble  clear  urine.  Personally,  I  have  never  seen  the  clear  fluid 
after  a  rupture  of  the  kidney,  and  I  have  cut  into  these  extravasations  of  very 
large  size  some  time  after  the  injury.  Clear  fluid  I  am  inclined  to  regard  as 
coining  from  a  rupture  of  the  renal  pelvis  or  ureter. 

Detachment  of  the  kidney  from  its  pedicle  is  very  rare  and  is  accompanied 
by -severe,  generally  fatal,  hemorrhage.  When  death  does  not  occur  at  once, 
infarction  and  necrosis  of  the  kidney  (extravasation  with  gangrene  of  the  peri- 
renal tissues)  are  liable  to  follow. 

Fracture  of  the  ribs  is  a  frequent  complication  of  renal  contusion.  The 
peritoneum  is  torn  in  some  cases  of  violent  injury,  an  accident  more  apt  to 
occur  in  children  under  ten  years  on  account  of  the  firm  connection  between  the 
peritoneum  and  the  kidney  at  this  early  age.  Other  abdominal  organs  nuiy,  of 
course,  suffer  coincidently  wdth  the  crushed  kidney. 

Symptoms. — The  Ukine. — When  a  kidney  is  torn,  even  slightly,  it  bleeds 
more  or  less  profusely.  Hemorrhage  is,  therefore,  the  most  important  consid- 
eration in  the  symptomatology  of  renal  contusions.  Of  all  forms  of  bleeding, 
hematuria  deserves  the  first  place,  because  it  is  the  most  frequent  and  the  most 
characteristic.  It  occurs  in  the  gTcat  majority  of  cases,  even  in  mild  injuries, 
and  is  lacking  only  when  there  is  a  small  tear  that  does  not  reach  the  calices, 
and  vdien  the  continuity  of  the  kidney  with  the  ureter  has  been  destroyed.  It 
Avill  thus  be  seen  that  it  is  not  always  an  alarming  symptom  per  se,  and 
that  its  absence  does  not  invariably  indicate  a  mild  injury.  Hematuria^ 
coming  on  after  injury,  does  not  mean  necessarily  a  contusion  of  the  kid- 
ney in  the  sense  that  Ave  are  considering;  for  if  a  calculus  is  present,  the 
bleeding  may   have   been   provoked   by   the   traumatism   of   the   stone   within 


SUBPARIETAL   INJURIES  393 

tlic  kidney,  as  aftei'  a  jar.  Blood  and  urine  pressing  on  the  outside  of  tlie 
])elvis  or  nretcr  may  prevent  licniatnria. 

The  hematuria  after  an  injury  to  the  kidney  may  be  profuse  at  once,  or 
slight  and  subsequently  increase ;  or  it  may  be  intermittent.  In  addition  to 
fresh  blood,  clots  or  casts  of  the  ureter  may  be  passed,  or  the  blood  clots  may 
accumulate  in  the  bladder  and  be  discharged  with  difficulty.  It  lasts  from 
two  to  eight  days  in  the  average  cases.  In  some,  it  may  continue  remittently  for 
weeks.     In  infected  cases,  secondary  hemorrhage  may  occur. 

Certain  conditions  that  aifect  the  character  and  amount  of  urine  passed 
occur  as  the  lesion  begins  to  interfere  with  the  function  of  the  kidney.  Oliguria 
and  even  anuria  may  result  if  a  blood  clot  occludes  the  ureter.  Later  polyuria 
may  occur,  either  simply  compensatory  in  character  or  indicating  the  presence 
of  a  traumatic  nephritis.  Albumen  and  pus  may  also  be  found  in  the  urine, 
indicating  the  j^resence  of  an  infection  and  renal  suppuration.  Together  Avitli 
hemorrhage,  w^e  should  look  for  the  general  symptoms  such  as  accompany  other 
abdominal  injuries,  and  are  summed  up  by  the  word  "  shock,"  symptoms  w^hich 
are  due  to  injury  to  the  solar  plexus  and  other  of  the  adjoining  nerve  plexuses 
as  well  as  the  loss  of  blood.  They  include  pallor,  cold  extremities,  cold  perspi- 
ration, a  small  and  rapid  pulse,  vomiting,  vertigo  and  prostration.  If  internal 
hemorrhage  be  severe,  there  are  added  to  this  gradual  blanching  of  the  skin  and 
mucosae,  a  thready  pulse,  anxiety  and  collapse.  If  peritonitis  comes  on  later, 
there  are  the  usual  general  symptoms  associated  with  this  complication. 

Local  Symptoms. — The  local  symptoms  generally  come  on  at  once  after  the 
injury,  although  they  are  sometimes  delayed.  They  include  pain  of  a  varying 
character,  usually  not  severe  when  due  only  to  the  injury  of  the  externfll  tissue 
or  to  fractured  ribs.  It  may,  however,  be  very  severe,  radiating  like  that  of  a 
renal  colic,  and  increasing  on  movement  and  often  upon  respiration.  Sometimes 
2)atients  complain  of  a  sensation  of  something  bursting  at  the  moment  of  injury. 

Retraction  of  the  cremaster  and  pain  in  the  testis  on  the  affected  side,  are 
regarded  as  signs  of  severe  renal  hemorrhage  and  of  blocking  of  the  ureters 
by  blood  clots  (Le  Dentu).  There  may  also  be  muscular  rigidity  over  the  in- 
jured organ.  The  renal  pain  may  last  for  weeks,  and  sensitiveness  on  pressure 
persist  for  a  long  time. 

Physical  Sic4ns. — The  skin  about  the  injured  loin  may  be  ecchymosed  or 
lacerated.  Ecchymosis  may  also  follow  the  connective-tissue  sheaths  of  the 
spermatic  vessels  and  thus  reach  the  external  abdominal  rings.  In  certain  cases, 
it  has  been  seen  to  extend  over  the  external  genitals.  A  characteristic  feature  of 
these  ecchymoses  due  to  renal  injuries  is  that  they  usually  reach  the  inguinal 
ring  late — two  or  three  weeks,  perhaps,  after  the  accident  (Sebilleau,  Dumenil, 
Le  Dentu) — but  it  must  be  remembered  that  they  nuiy  also  be  due  to  injuries 
of  other  vessels  in  the  retroperitoneal  tissues. 

The  swelling  may  be  very  slight  in  mild  injuries,  but  it  is  always  distinct 


394  KIDNEY   INJUKIES 

in  the  more  severe  forms.  It  usually  comes  on  suddenly  in  severe  cases  and 
depends  upon  the  amount  of  the  effusion  of  blood  and  urine.  The  tumor  is  usu- 
ally palpable  even  in  mild  cases  and  is  dull  on  percussion,  when  the  swelling 
is  suthcicutly  larae  to  percuss  well. 

Complications. — The  complications  are  aseptic  or  infectious  in  character. 
Aseptic  complications  are  intraperitoneal  hemorrhage,  and,  rarely,  traumatic 
nephritis.  Infectious  complications  are  peritonitis,  perinephritic  abscess  and 
pyelo-nephritis. 

Peritoxeal  Co:^ir'LiCATioxs. — Effusions  of  blood  into  tlie  peritoneum  occur 
when  the  injury  includes  a  rent  in  that  mendjrane,  or  when  the  liver,  spleen, 
or  some  other  organ  is  torn.  A  septic  peritonitis  develops  within  a  short  time 
when  infected  urine  flows  into  the  cavity  along  with  the  blood.  However,  this 
is  fortunately  not  a  connnon  occurrence,  as  the  peritoneum  is  fairly  resistant 
to  aseptic  urine.  According  to  experiments  quoted  by  Wagner,  such  urine  is 
borne  by  the  peritoneum  for  forty-eight  hours  without  much  damage.  As- 
cending and  hematogenous  infections  may  also  attack  the  peritoneum  in  sub- 
cutaneous injuries  of  the  kidneys   (de  Quervain). 

De  Quervain  noted  that,  owing  to  disturbances  in  circulation  of  the  colonic 
flexure  on  the  affected  side,  a  certain  degree  of  meteorism  was  often  present 
without  any  peritoneal  involvement.  This  is  a  point  worth  remembering,  as 
such  tympanites  are  apt  to  mislead  one  into  the  diagnosis  of  traumatic 
peritonitis. 

Chko]n^ic  Traumatic  Xepheitis. — Chronic  traumatic  nephritis,  as  a  com- 
plication of  subcutaneous  renal  injuries,  deserves  a  few  additional  words,  as  it 
•has  been  the  subject  of  considerable  controversy.  It  is  not  certain  Avhether  a 
diffuse  nephritis  can  follow  such  an  injury,  and  it  is  probable  that  in  the  cases 
in  which  diffuse  renal  lesions  were  found  at  autopsy  after  contusions  of  the 
kidney,  the  patient  had  been  suffering  from  chronic  nephritis  before  the  injury. 
Circumscribed  nephritic  lesions  may  occur,  however,  in  the  areas  immediately 
involved.  In  such  cases,  which  are  rare,  the  albuminuria  and  the  casts  persist 
for  some  time  in  the  urine  after  the  hematuria  disappears.  Albumin  has  been 
found  in  small  amounts  for  a  year  or  more  after  the  injury. 

Diagnosis. — The  diagnosis  of  a  renal  contusion  is  possible  i-n  a  positive  way 
wdien  hematuria  is  present.  All  other  symptoms  may  lead  us  to  suspect  such  a 
lesion,  but  none  is  sufficiently  characteristic.  This  does  not  mean  that  they  must 
not  be  looked  for  carefully.  The  existence  of  a  perirenal  hematoma,  coupled 
with  the  history  of  the  case,  has,  however,  gTcat  value. 

The  differentiation  between  a  subparietal  renal  injury  and  a  renal  colic 
due  to  calculus  and  preceded  by  an  accidental  traumatism,  is  not  always  easy. 
The  history  of  the  case  and  the  repetition  of  the  attacks  at  intervals  may  help 
in  making  this  distinction  in  the  limited  time  at  our  disposal  in  these  cases. 
Renal  tumors  often  give  rise  to  pain  and  hematuria  after  an  accidental  blow, 


SUBPARIETAL    INJURIES 


395 


and,  in  sncli  cases,  the  diagnosis  will  have  to  he  reserved  until  tlio  nrino  and 
the  cachexia  .give  a  clew  to  the  condition. 

We  liave  seen  tliat  I  lie  sc^verity  of  the  symptonis  is  l)y  no  means  a  measnre 
(if  the  extent  of  the  injury  in  snhcntaneous  renal  traumatism.  An  exception 
to  this,  perhaps,  is  the  rajiidity  Avith  which  the  renal  hematoma  develops.  This 
is  usually  proportionate  to  the  severity  of  tlie  injury. 

In  cases  with  slight  or  ahsent  swelling  and  i)ain,  hut  with  persistent  hema- 
turia, the  cystoscope  will  show  from  which  side  the  bleeding  comes.  Muscular 
rigidity  on  the  affected  side  is  of 
service  in  doubtful  cases. 

In  another  class  of  cases,  the 
l)lceding  continnes  slowdy  until  a 
tumor  resembling  a  small  water- 
melon in  shape  and  size  develops 
on  one  side  of  the  abdomen,  most 
nuirked  in  front  (Fig.  268).  In 
this  case,  a  lumbar  incision  should 
be  made  in  the  ileo-costal  space  be- 
hind and  the  contents  evacuated. 
The  amount  of  mixed  nrine  and 
blood  in  such  cases  is  often  as- 
tounding. 

Prognosis. — The  prognosis  of 
renal  contusions  varies  with  the 
severity  of  the  lesion.  The  chief 
danger  is  from  complications,  and 
recoveries  are  on  record  of  patients 
who  have  been  in  an  apparently 
hopeless  condition.  Death  nraj  oc- 
cur within  a  short  time  as  a  result 
of  collapse  from  hemorrhage.  If 
the  patient  lingers  on,  complica- 
tions may  be  feared.  According  to  Morris,  in  rupture  of  the  kidney,  its  pelvis, 
or  ureter,  the  prognosis,  as  far  as  life  is  concerned,  is  less  favorable  than  in 
rupture  of  other  abdominal  organs. 

Statistics  of  mortality  from  subparietal  renal  injuries  vary  souiewhat. 
Edler  gives  fifty  per  cent  mortality,  Kiister  forty-seven  per  cent.  Keen  thirty- 
three  per  cent,  but  Albarran  thinks  that  these  figures  are  exaggerated,  as  he  saw 
seven  cases  without  a  death  and  as  Le  Dentn  notes  that  recovery  took  place  in 
nearly  all  cases  observed  by  him.  Guyon,  at  the  ISTecker  Hospital  for  the  past 
ten  years,  does  not  record  a  single  fatal  case.  The  high  mortality  figures  are 
due  probably  to  the  fact  that  only  the  grave  cases  are  published.     Hemorrhage 


Fig.  268.  —  Shape  of  the  Abdomen  in  the  Case 
OF  A  Ruptured  Kidney.  The  rupture  extended 
into  the  renal  pelvis.  There  was  a  slow  leakage 
of  blood  and  urine.     (Author's  case.) 


396  KIDNEY   INJURIES 

and  siippiiration  are  the  most  frequent  causes  of  death.  Wagner  could  find 
hut  three  cases  on  record  where  the  patient  recovered  from  a  renal  contusion 
complicated  by  a  demonstrable  tear  in  the  peritoneum.  Kiister  considers  these 
cases  as  offering  the  most  unfavorable  prognosis.  The  question  of  prognosis 
bears  directly  on  the  question  of  treatment. 

Treatment. — In  mild  and  moderately  severe  cases,  renal  contusion  heals 
spontaneously,  in  -which  case  there  is  no  place  for  active  surgical  interference. 
In  fact,  such  patients,  when  kept  in  bed,  with  strips  of  adhesive  plaster  across 
the  back,  recover  quite  well  in  a  very  large  proportion  of  cases.  The  usefulness 
of  ice  bags  is  doubtful. 

In  complicated  cases,  rest  in  bed  should  be  maintained  for  a  week  or  longer, 
after  the  swelling  and  all  traces  of  bleeding  have  disappeared.  Shock  should 
be  treated  in  the  usual  way,  but  cases  of  rupture  of  the  kidney  must  be  very 
carefully  watched  and,  if  the  shock  is  great,  the  pulse  thready,  indicating  in- 
ternal hemorrhage,  rapidly  increasing,  an  incision  should  be  made  and  the 
wound  in  the  kidney  repaired  by  suture,  if  not  too  extensive.  If,  however,  the 
kidney  is  badly  lacerated,  an  immediate  nephrectomy  is  indicated. 

If  the  renal  hemorrhage  is  found  to  be  active,  the  kidney  must  be  repaired 
or  removed.  In  two  such  cases  of  my  own,  after  evacuating  the  contents  and 
packing  the  cavity,  the  hemorrhage  ceased.  Later  I  removed  the  kidney  in  one 
of  these,  on  account  of  infection  and  the  great  damage  done  to  the  kidney. 

Still  another  indication  for  operative  intervention  is  given  by  the  late  in- 
fection and  suppuration  of  a  perirenal  hematoma.  This  may  require  an  opera- 
tion three  weeks  after  the  accident.  The  kidney  is  sometimes  necrotic  and  has 
.to  be  removed. 

To  sum  up  in  a  few  words :  The  immediate  indication  for  operation  is  hem- 
orrhage ;  the  late  indications  are  perirenal  accumulations  and  infection. 

The  results  of  operative  treatment  as  contrasted  with  the  nouopcrative  treat- 
ment, are  tabulated  thus  by  Morris  (vol.  i,  p.  198). 

In  twenty-six  cases  collected  from  English  and  American  sources  from  ISSi 
to  1893  inclusive,  he  found: 

One  died  of  other  causes. 

Fourteen  treated  palliatively,  ten  died — 70.7  per  cent. 

Eleven  treated  by  operation,  three  died — 27.2  per  cent. 

This  is  not  absolutely  convincing  jn'oof  of  the  superiority  of  the  operative 
method.     My  personal  results  to  date  are: 

One  treated  palliatively,  no  death. 

Eour  treated  by  operation,  one  death. 

Illustrative  Cases. — I  will  give  a  brief  resume  of  the  five  eases  of  sub- 
parietal  injury  of  the  kidney  I  have  had. 

Case  I. — Case  of  subparietal  subcapsular  injury  of  the  right  kidney.  The 
patient  was  a  laborer,  thirty-eight  years  of  age,  who  one  week  before  seeking 


SUBPARIETAL   INJURIES 


397 


admission  to  the  liospital  had  a  fall,  striking  on  the  right  side.  This  was  fol- 
lowed by  pain  in  the  loin  and  inability  to  pass  urine  for  twenty-four  hours; 
when  he  finally  ])assed  urine,  it  was  red  in  color. 

Stains  pnvf^ens:  A  mass  the  size  of  a  coeoanut,  dull  on  jx-rcussion  behind,  is 
felt  in  the  right  lumbar  region.     Local  pain  and  tenderness.     No  temperature. 

Urine:  Of  a  Burgundy-red  color.  S|:>ecific  gravity,  1.022.  Albumin, 
twenty-five  per  cent  in  bulk.     Some  leucocytes  and  abundant  red  corpuscles. 

Treatment:  Rest  in  bed;  milk  and  Vichy  diet;  urotropin  and  Basham's 
mixture. 

Course:  The  patient  remained  in  the  hospital  five  weeks.  At  the  end  of 
the  first  week,  the  urine  was  straw-colored,  specific  gTavity  1.019,  of  acid  reac- 
tion and  contained  a  few  blood  cells  and  calcium  oxalate  crystals.  By  the  end 
of  the  second  week,  three  weeks  after  the  accident,  all  traces  of  blood  had  dis- 
appeared from  the  urine,  and  the  tumor  was  diminishing  in  size.  It  could 
scarcely  be  felt  at  the  time  of  discharge,  five  weeks  later. 

Case  II. — The  patient,  a  laborer,  twenty-two  years  of  age,  eleven  days  before 
admission  fell  while  dumping  a  box  of  dirt,  and  struck  the  ground  on  the  left 
side  from  a  distance  of  twenty-five  feet.  He  was  unable  to  walk  and  had  to  be 
carried  home.  A  few  days  later,  the  painful  swelling,  that  had  been  gradually 
increasing  in  size,  occupied  the 
entire  left  side  of  the  abdomen. 
The  general  symptoms  increased 
in  severity,  and  the  patient  en- 
tered the  hospital. 

Status  'proesens:  There  was  a 
swelling  in  the  left  side,  resem- 
bling a  small  watermelon  in  form, 
dull  on  percussion  (Fig.  268). 
Temperature  101°  to  106°  F. ; 
pulse,  88 ;  respiration,  20.  There 
was  no  visible  hematuria.  The 
local  findings  led  to  the  diagnosis 
of  splenic  rupture. 

Treatment:  Operative.  An  in- 
cision was  made  in  front,  along 
the  outer  border  of  the  rectus 
muscle,  and  the  peritoneal  cavity 
was  opened.  The  gut  Avas  found 
stretched  between  the  anterior 
and  posterior  peritoneal  walls  like 
pieces  of  ribbon,  due  to  a  retroperitoneal  tumor  that  was  pushing  forward  the  ab- 
dominal contents.     The  patient  was  accordingly  turned  and  an  incision  made  in 


Fig.  269. —  Rupture  of  Kidney.  IShows  the  rent  in 
the  kidney  proper  and  pelvis  of  a  ruptured  kid- 
ney. The  kidney  is  turned  so  as  to  show  the  tear. 
(Author's  case.) 


398  XTDXEY    TX.TT^rJES 

tlic  loin  l)cliin(l,  wlicii  Iwo  and  onv  half  lialloiis  of  a  rcddisli-hrown  l)]ood_v  fluid 
escajjed.  The  kidney  was  found  i'U])tui'cd  poslcriorly,  sliowiiiii-  a  ti-aiisverse  rent 
in  the  kidney  proper  extending  into  the  ijclvis  ihat  achnitted  three  fingers.  The 
opening  was  just  ahove  and  posterior  to  the  ureter.  The  organ  was  snrronnded 
by  a  dense  mass  of  tissne  and  very  adlierent  to  tlie  adjacent  parts.  The  wound 
was  packed  and  drained,  hnt  a  week  later  the  drainage  became  impaired,  and 
there  was  much  pain  and  distress.  Reopening  of  wound  and  removal  of  two  and 
one  half  quarts  of  a  brownish  fluid  containing  pus.  Nephrectomy  one  month 
later.     The  patient  recovered  (Fig.  2G9). 

Case  III. — The  patient  was  a  grocer,  thirty-one  years  of  age,  who  three  weeks 
previously,  following  a  fall,  began  to  suffer  from  pain,  gradually  increasing,  and 
swelling  in  the  left  lumbar  region,  with  anorexia  and  constant  thirst.  Xo  irregu- 
larities of  urination.     No  visible  hematuria. 

Status  prwsens:  A  large  tumor,  not  sharply  defined,  also  shaped  like  a 
melon,  was  felt  in  the  left  lumbar  region.  Temperature,  102°  to  103°  F. ; 
pulse,  98. 

Treatment:  Operative.  A  lumbar  incision  was  made,  and  a  large  amount  of 
a  brownish  fluid  like  broken-down  kidney  tissue  was  removed.  The  cavity  was 
packed  with  gauze.  Suppuration  followed,  and  the  patient  remained  in  the 
hospital  for  two  months,  when  he  was  discharged  with  the  wound  in  the  kidney 
healed. 

Case  IV.— The  patient,  a  housewife,  thirty-six  years  of  age,  had  complained 
for  eight  years  of  occasional  pain  in  the  right  lumbar  region,  with  fever,  last- 
ing from  a  few  hours  to  days.  For  some  time  before  coming  under  treatment, 
she  had  noticed  an  increasing  fullness  in  the  lumbar  region.  Examination 
showed  a  well-defined  tumor  on  the  right  side,  extending  from  the  costal  mar- 
gin to  the  iliac  fossa,  beyond  the  umbilicus.  There  was  another  bulging  in  the 
ileo-costal  space  behind.  At  this  time  the  patient's  temperature  was  101°  F. ; 
pulse,  94;  respiration,  36.  She  was  sent  to  the  hospital  in  an  ambulance,  and 
at  the  time  of  admission,  a  few  hours  after  the  first  examination,  her  tempera- 
ture was  105°  to  10G°  F. ;  pulse,  130;  respiration,  46.  No  well-defined  tumor 
could  be  outlined  in  the  examination,  but  there  was  a  general  mass  over  the  en- 
tire right  side  of  the  abdomen.  It  was  evident  that  the  ride  in  the  ambulance  had 
caused  rupture  of  the  kidney  and  leakage  into  the  postrenal  space.  An  in- 
cision was  made  the  next  day,  and  a  large  amount  of  blood  and  pus  evacuated. 
The  temperature  dropped  at  first,  but  then  ran  a  septic  course  due  to  imperfect 
drainage.  The  kidney  on  removal  was  found  to  contain  a  stone.  The  outcome 
was  death. 

Case  V. — The  patient  was  a  man  twenty-nine  years  of  age,  an  ironworker 
by  occupation,  who  gave  a  history  of  many  attacks  of  malaria.  Two  years  ago 
he  had  pain  in  the  right  loin,  lasting  four  or  five  days,  and  this  had  recurred 
since  at  intervals  of  four  or  five  months,  with  a  little  fever,  lasting  for  hours 


IT^[CISED,    PUNCTURED    AND    GUNSHOT    WOUNDS  399 

or  cla^^s.  Four  inoiillis  Ix'fore  coining  nndor  troatiiicnt,  tlio  patient,  while 
lifting'  a  piece  of  metal,  heard  something  snaj)  on  the  right  side;  this  was 
followed  hy  faintness  and  cold  perspiration.  There  was  a  strong  desire  to 
nrinate,  and  the  nrine  passed  Avas  bloody,  remaining  tnrhid  ever  since  that 
time.  At  the  time  of  admission,  the  patient  had  a  se])tic  temperature,  aver- 
aging 100°  F. ;  his  general  condition  was  bad.  A  large  mass  could  be  felt  in 
the  right  side. 

Treatment :  Operative.  An  incision  was  made  in  the  loin,  and  three  pints 
of  mixed  nrine,  blood  and  pus  were  evacuated.  A  ragged  opening  was  found 
in  the  lower  pole  from  wdiich  protruded  a  fragment  of  stone,  over  an  inch  in 
length  and  one  third  of  an  inch  in  width.  The  wound  was  packed.  The 
temperature  dropped  after  the  operation ;  the  wound  did  not  heal  and  a  sinus 
remained,  discharging  urine  and  pus.  ]^ephrotomy  was  performed,  followed 
by  free  drainage  of  the  kidney,  and  the  patient  left  the  hospital  one  month 
later  in  good  condition. 

INCISED,  PUNCTURED  AND  GUNSHOT  WOUNDS  OF  THE  KIDNEY 

Etiology. — Incised  and  punctured  wounds  of  the  kidney  are  almost  always 
due  to  a  thrust,  or  to  a  fall  on  something  sharp,  as  a  pointed  weapon.  The  kid- 
ney is  generally  alone  aifected,  as  the  wound  is  usually  due  to  the  stab  of  a  knife 
in  the  back  or  side,  and  the  opening  of  the  peritoneal  cavity  is  infrequent.  Still 
rarer  is  a  complete  division  of  the  organ.  When  the  kidney  wound  results  from 
a  thrust  through  the  anterior  wall  of  the  abdomen,  the  other  abdominal  organs 
are  usually  injured  as  well. 

The  wound  may  vary  considerably  in  depth  and  direction.  As  these  wounds 
are  often  inflicted  by  septic  instruments,  it  is  not  surprising  that  they  fre- 
quently become  septic. 

Gunshot  wounds  are  rarely  seen  in  civil  practice,  and  in  war  they  are  al- 
most always  complicated  with  gunshot  injuries  of  other  organs  on  account  of 
the  high  velocity  of  modern  firearms.  Edler  states  that  these  wounds  constitute 
about  one  twelfth  of  one  per  cent  of  all  gunshot  injuries.  Only  tln-ee  cases  are 
on  record  in  women. 

Pathology. — The  bullet  may  remain  in  the  kidney  and  become  encysted 
there,  or  it  may  pass  through  the  organ,  or  it  may  graze  it  and  cut  oif  a  ])iece 
of  renal  substance,  or  pass  through  the  renal  pelvis.  Fragments  of  cloth,  bone, 
etc.,  may  be  carried  with  the  bullet  and  remain  in  the  track  of  the  projectile. 
There  is  alwa^'S  a  certain  amount  of  contusion  along  this  tract,  and  an  escliar 
forms  in  its  walls.  The  kidney  may,  however,  be  mashed  to  a  pulp  by  the 
projectile.  The  orifices  of  entrance  and  exit  are  of  \mequal  size,  the  latter 
being  usually  the  larger.  Stellate  fissures  radiate  from  these  openings  when- 
the  kidney  is  flaccid,  or  a  long  and  wide  fissure  results  when  it  is  distended  at 


400  TaDXKY   INJURIES 

the  time  of  the  injury.  Unless  the  ])_vr:iiiii(ls  oi'  cnlices  l)e  \voun(h'(l,  no  hlood 
escapes  an(]  thci'e  is  but  liitU'  hematuria  at  first  in  the  average  case,  llioniih 
hlood  nuay  accumulate  in  the  perineal  space. 

These  wounds  heal  by  granulation  followed  by  the  formation  of  cicatricial 
tissue,  after  the  slough  has  separated  from  the  tissues  and  has  been  discharged. 

Foreign  bodies  carried  in  with  the  bullet  nuiy  become  encysted  in  the  kid- 
ney, or  pass  into  the  ureter  or  through  the  external  \v<iun<l.  Fistula-  are  fre- 
quent sequela'. 

Symptoms. — They  are  the  same  as  those  of  contusion ;  namely,  hemorrhage 
and  shock  and  a  wound  in  the  lower  region  or  in  the  abdomen  below  the 
costal  arch.  Pain  in  the  wound,  radiating  along  the  ureter,  is  a  very  variable 
feature.  The  hemorrhage  may  take  j^lace  externally,  internally,  or  through  the 
ureter. 

External  hemorrhage  alone  is  exceptional.  It  is  generally  associated  with 
hematuria.  The  latter  is  rarely  absent  and  may  be  an  early  sign.  The  amount 
of  hematuria  is  much  greater  in  proportion  to  the  internal  perirenal  as  well  as 
the  external  hemorrhage.  When  the  outer  wound  is  large,  there  is  considerable 
external  bleeding  and  generally  very  little  lumbar  swelling.  If  the  calices  or 
pelvis  are  wounded,  urine  will  be  mixed  with  the  blood.  In  gunshot  wounds, 
the  immediate  hemorrhage  may  be  slight,  owing  to  the  presence  of  a  clot,  but 
when  a  slough  separates,  after  five  or  six  days,  there  may  be  a  profuse  secondary 
hemorrhage.  Prolapse  of  the  kidney  through  the  wound  is  extremely  rare. 
The  symptoms  of  renal  injury  may  be  obscured  by  those  of  the  other  abdominal 
organs  simultaneously  involved.  Retention  of  urine  in  the  kidney  may  be 
caused  by  a  clot  clogging  the  ureter.  The  complications  are  all  referable 
to  infection  and  consist  in  j)eritonitis,  nephritis,  pyelitis  and  perinephritic 
abscess. 

Diagnosis  and  Prognosis. — The  situation,  direction  and  origin  of  the 
wound,  hematuria,  hemorrhage  from  the  external  wound,  or  ordinary  extravasa- 
tion, are  the  chief  guides  in  the  diagnosis.  In  case  there  is  an  escape  of  urine 
from  the  wound,  the  odor  of  the  fluid  is  usually  strong  enough  to  prevent  errors ; 
but,  if  there  is  any  doubt,  an  examination  as  to  the  presence  of  urea  can  be 
made.  A  digital  examination  of  the  wound  should  be  resorted  to  in  doubtful 
cases.  Lumbar  pain  and  hematuria  are  reliable  signs  of  a  renal  woimd  in  these 
cases.  The  sounding  of  gunshot  wounds  is  only  permissible  under  circumstances 
pointing  to  the  presence  of  a  foreign  body.  The  X-ray  will  often  locate  the 
bullet. 

The  prognosis  is  always  grave  and  depends  largely  upon  coincident  infec- 
tion, upon  peritoneal  penetration  and  upon  the  participation  of  the  renal  pelvis 
and  renal  vessels  in  the  injury.  Albarran  gives  the  general  mortality  as  fifteen 
per  cent.  Of  forty-three  cases  of  punctured  and  incised  wounds  of  the  kidney 
collected  by  Klister,  ten    (twenty-three  per  cent)    ended  fatally.      The  death 


INCISED,   PUNCTURED    AND    GUNSHOT   WOUNDS  401 

rate  has  been  considerably  lessened  by  operative  treatment.  Experience  in  the 
South  African  War,  according  to  Morris  (vol.  i,  p.  238)  showed  that  penetrat- 
ing wounds  of  the  kidney,  cansed  by  modern  small-bore  l)nllets,  do  not  neces- 
sarily have  a  fatal  issue,  even  when  other  organs  are  traversed,  and  that  the 
kidney  or  the  liver  may  be  ])ierced  from  before  backward  or  from  side  to 
side,  without  any  symptoms  of  importance  following.  These  fortunate  cases 
are  duo  to  the  fact  that  small-bore  bullets  do  not  lacerate  and  make  very  small 
wounds — a  fact  that  has  altered  many  aspects  of  military  surgery  within 
receut  years. 

Treatment. — The  general  treatment  is  that  of  shock  and  hemorrhage, 
consisting  in  stimulation  for  the  former,  and  a  hot  saline  enema  or  in- 
travenous injection  for  the  latter.  A  simple  antiseptic  bandage  should  be 
placed  over  the  wound,  and,  if  the  patient's  general  condition  improves, 
the  treatment  should  be  expectant  and  symptomatic.  I  do  not  believe  in 
closing  the  w^ound,  although,  if  it  is  very  large,  the  edges  can  be  brought 
together  by  surgical  plaster,  allowing  sufficient  space  for  the  escape  of  blood 
and  bloody  urine. 

If  the  hemorrhage  is  severe,  and  the  patient  does  not  rally  under  stimu- 
lants, the  case  becomes  an  emergency  one,  and  a  wide  lumbar  incision  must  be 
made,  the  kidney  reached  and  sutured,  leaving  a  drain  from  the  surface  of  the 
kidney  to  the  outer  dressings.  If  the  organ  be  found  too  extensively  involved, 
a  quick  nephrectomy  should  be  performed. 

To  sum  np :  Put  on  an  antiseptic  bandage  with  an  ice  bag  over  the  wound, 
counteract  shock,  check  the  hemorrhage,  keep  the  patient  quiet  and  he  as  con- 
servative as  possible.  Such  are  the  guiding  rules  for  the  treatment  of  all  kid- 
ney wounds. 

Illustrative  Case. — I  have  had  only  one  case  of  punctured  wound  of 
the  kidney,  a  laundryman,  twenty  years  of  age,  who  was  stabbed  in  the 
loin  from  behind  jast  above  the  twelfth  rib,  and  was  able  to  walk  to  the 
hospital. 

Status  prcesens:  There  was  a  wound,  about  three  quarters  of  an  inch  in 
length,  in  the  lumbar  region,  and  a  mass  was  present  resembling  an  enlarged 
kidney.  The  patient  vomited  and  complained  of  pain  in  the  loin.  His  pulse 
and  temperature  were  normal. 

Treatment:  Internally,  1.5  minims  of  the  fluid  extract  of  ergot  given 
every  three  hours,  and  urotropin  given  every  six  hours.  Wet  dressings  on 
the  loin. 

Course:  On  the  following  day,  he  urinated  a  quart  of  red  blood  and  con- 
tinued to  pass  bloody  urine  for  seven  days,  when  it  became  clear  and  he  left  the 
hospital.  Two  days  later  he  began  to  suifer  from  frequency  of  urination,  void- 
ing every  three  hours,  and  on  the  following  day  again  passed  red  urine.  There 
was  severe  pain  over  the  pubic  region,  and  the  patient  reentered  the  hospital, 


402 


KIDNEY   INJURIES 


where  lie  was  catheterized  and  a  quart  of  bloody  urine  was  drawn  off.  At  no 
time  did  he  have  any  fever.  The  hematuria  ceased  altogether  at  the  end  of 
two  weeks  after  the  accident,  when  he  left  the  hospital.  The  renal  hematoma  in 
the  loin  persisted  during  the  whole  time,  and  was  still  present  on  the  right 
side  at  the  time  of  the  discharge. 


CHAPTEK    XXII 

MOVABLE  KIDNEY 

Movable  kidney  is  frequently  referred  to  as  floating  kidney,  but  more 
correctly  speaking  a  movable  kidney  is  one  that  has  an  abnormal  range  behind 
the  peritoneum  in  a  vertical  plane,  while  a  floating  kidney  is  one  with  a  meso- 
nephron  which  floats  among  the  abdominal  viscera. 

The  kidney  is  held  in  place  by  the  fatty  capsule  which  surrounds  it,  the 
perirenal  fascia,  the  suprarenal  capsule  to  which  it  is  adherent,  the  renal  pedi- 
cle, and  thi'ough  the  intra-abdominal  pressure.  The  perirenal  fascia  (see  Fig. 
30)  incloses  it  on  all  sides,  but  is  open  at  the  lower  inner  part,  in  which  direc- 
tion the  kidney  tends  to  move.  There  is  normally  some  mobility  of  the  kidney, 
from  3  to  5  cm.,  greater  in  women  than  in  men,  depending  upon  the  length  of 
the  vascular  pedicle.  It  may  be  said  that,  whenever  a  kidney  can  be  felt  pro- 
jecting below  the  ribs,  moving  on  respiration  and  sensitive  to  the  touch,  it  may 
be  considered  movable  in  the  pathological  sense.  The  frequency  in  autopsy 
findings  differs  greatly  from  the  clinical  statistics.  For  instance,  Epstein,  in 
compiling  postmortem  statistics,  found  that  it  had  occurred  once  in  500  cases  and 
iSTewman  estimated  1  to  1,000  ;  while,  clinically,  Kutnow  found  it  in  20  per  cent, 
Glenard  in  22  per  cent,  Goddard-Danhieux  in  35  per  cent  of  women  and  21.35 
per  cent  in  men,  and  Harris  in  over  50  per  cent  in  women,  while  in  men  it  was 
present  in  2.3  per  cent.  I  believe  it  is  safe  to  say  that  it  occurs  in  10  per  cent 
of  women,  although  I  think  the  percentage  of  those  who  suft'er  to  any  marked 
degree  from  the  mobility  is  much  less. 

Three  degrees  of  movable  kidney  are  spoken  of :  First,  when  the  lower  half 
of  the  kidney  is  palpable  (Fig.  270,  I)  ;  second,  when  the  entire  organ  is  pal- 
])al)le  (Fig.  270,  II)  ;  tliird,  when  the  entire  organ  can  both  be  palpated  and  is 
freely  movable  downward  and  inward  (Fig.  270,  III).  The  third  degTce,  ac- 
cording to  Glenard,  constitutes  a  floating  kidney.  The  organ  is  at  times  even 
more  movable  and  has  been  found  in  the  female  pelvis,  from  which  position  it 
has  been  removed  by  operators  who  mistook  it  for  a  cystic  ovary.  When  it  moves 
away  from  the  loin,  its  usual  rotation  is  downward  and  inward,  and,  as  it  pro- 
gi-esses,  its  lower  pole  moves  forward  and  its  upper  pole  tends  to  point  backward. 
(See  Fig.  270,  III).     It  sometimes  pulls  on  the  duodenum  and  often  makes  an 

403 


404 


MOVABLE    KIDNEY 


extensive  excursion  with  the  ascending  and  hepatic  flexnre  of  the  colon,  espe- 
cially when  there  are  adhesions  to  one  or  the  other  of  these  viscera. 

In  mild  degrees  of  movable  kidney,  the  ureter  gives  rise  to  no  trouble ;  but 
when  the  displacement  is  marked,  it  may  curve  or  kink,  although  still  allowing 
the  urine  to  pass  through  it,  but  less  easily  than  under  normal  conditions.    This 


Fig.  270. 


-Displacement  of  the  Kidney,  Showing  (I,  II,  III)   the  First,  Second  and  Third  De- 
grees OF  Displacement.     (Kelly's  "Medical  Gynecology.") 


may  interrupt  temporarily  the  flow  of  urine  (Fig.  271).  When  the  kinks  are 
held  by  adhesions,  the  course  of  the  urine  may  be  seriously  impeded,  giving  rise 
to  retention  of  urine  in  the  renal  pelvis  and  attacks  of  pain. 

The  suprarenal  capsule  does  not  move  with  the  kidney.  The  peritoneum 
over  the  kidney  may  become  loosened  and  elongated  and  accompany  it  in  its 
excursion,  resembling  a  mesonephron. 

Etiology. — The  etiology  of  movable  kidney  is  still  a  subject  for  discussion. 
Women  are  predisposed  to  this  condition.  The  relative  frequency  in  men  and 
women  is  variously  estimated  from  1  in  7  to  1  in  1.5.  In  my  practice  it  is  1  to  5, 
but  presumably  because  my  male  patients  are  more  numerous.     The  reason 


ETIOLOGY 


405 


for  this  predisposition  in  women  is  that  the  renal  fossa,  i.  e.,  the  hollow  in  the 
loin  where  the  kidney  rests,  is  shallower  in  the  female.  It  is  also  more  open 
below  and  narrower  at  the  upper  part,  where- 
as in  men  the  fossa  is  deeper  and  narrower 
at  the  lower  part. 

The  most  favorable  period  for  the  devel- 
opment of  this  condition  is  that  of  gestation, 
althongh  it  is  freqnently  fonnd  in  young 
girls  and  has  been  reported  in  infants.  The 
riiiht  side  is  affected  in  between  85  and  90 
per  cent  of  the  cases  on  account  of  the  longer 
pedicle,  the  pressure  transmitted  to  the  kidney 
by  the  liver  during  respiration,  and.  pressure 
from  corsets,  waistbands,  belts  and  girdles.  H 

Pregnancy  is  considered  an  important 
cause,  especially  when  frequently  repeated 
at  short  intervals  and  followed  too  soon  by 
exertion.  Multiparse  are  affected  more  fre- 
quently than  nulliparae,  in  a  proportion  vari- 
ously estimated  at  from  20  to  1,  to  from  5 
to  1.  This  tends  to  show  the  importance  of 
intra-abdominal  pressure  in  the  sujDport  of 
the  kidneys  and  the  fact  that  the  abdominal 
Avail,  if  its  muscles  are  strong  and  well  devel- 
oped, serves  as  a  bandage  with  the  intestine  acting  as  an  elastic  pad.  It  also 
emphasizes  the  importance  of  preserving  the  strength  of  the  abdominal  wall. 
In  cases  where  this  is  much  weakened  after  pregnancy,  the  w'oman  should 
remain  in  bed  until  it  has  become  stronger  and,  when  she  resumes  her  usual 
household  duties,  an  abdominal  support  or  belt  should  be  worn. 

A  loss  of  fat  is  usually  spoken  of  as  an  important  cause,  but  this  is  not 
especially  noted  in  the  fatty  capsule  at  the  time  of  operation  in  thin  subjects. 

The  question  as  to  the  connection  of  nephroptosis  with  general  enteroptosis 
has  been  discussed  by  many  and,  according  to  Glenard,  it  is  but  a  part  of 
enteroptosis,  the  latter  being  a  disease  of  general  bad  nutrition,  accompanied 
by  the  falling  forward  and  downward  of  all  the  abdominal  viscera.  Glenard's 
views,  however,  are  not  universally  accepted  and  I  think  it  is  safe  to  say  that 
while  nephroptosis  has  no  tendency  to  produce  general  enteroptosis,  that  the 
latter  condition  may  assist  in  producing  the  former. 

All  observers  seem  to  agree  that  the  corset  and  the  tight  waistbands  of  heavy 
skirts  in  women,  and  the  tight  belts  supporting  the  trousers  in  workingmen, 
are  common  causes  of  this  condition.  Corsets  and  waistbands  supporting  heavy 
clothing  do  evidently  have  a  traumatic  influence  on  the  kidney,  as  the  former 


Fig.  271.  —  Kinking  of  the  Ureter 
IN  Displacement  of  the  Kidney. 
This  kinking  of  the  ureter  may 
interrupt  temporarily  the  flow  of 
urine,  leading  to  the  formation  of  an 
intermittent  nephrydrosis  (hydro- 
nephrosis). (Harris,  in  Reed's  "  Text- 
book of  Gynecology.") 


406  MOVABLE   KIDNEY 

ill  many  iiioveineiits  tend  to  push  the  liver  against  the  kidney;  whereas,  if  the 
kidney  is  disphiced  and  it  is  2)ressed  upon  by  a  thin  belt  or  waistljaiid,  the 
weight  of  the  clothes  tend  to  drag  the  kidney  down  diirinj;'  certain  niDN'cniciils, 
as  when  the  patient  bends  forward  in  the  act  of  scrubbing,  washing,  or  in  other 
motions  of  a  similar  nature.  The  lifting  of  heavy  weights,  reaching  for  high 
objects,  straining  at  stool,  chronic  hacking  cough,  horseback  riding  and  the 
skijiping  rope  also  tend  gradually  to  displace  the  kidney.  These  can  all  be 
spoken  of  as  repeated  traumatisms  of  a  mild  character. 

I  feel  that  the  claims  that  sudden  traumatism  causes  movaljle  kidney — siudi 
as  a  blow  in  the  loins,  a  fall  upon  the  knees,  buttocks  or  perineum,  a  blow  on 
the  thorax,  a  sudden  muscular  strain  due  to  the  abrupt  stopping  of  a  car  and 
other  claims  of  a  similar  nature  which  are  used  in  suing  corporations  and 
railway  companies — are  groundless.  In  all  such  cases,  if  the  traumatism  had 
been  sufiicient  to  displace  the  kidney  suddenly,  it  would  have  been  grave  enough 
to  have  ruptured  the  vessels  or  the  renal  pedicle  and  given  rise  to  a  dangerous 
hemorrhage,  and,  perhajis,  sudden  death.  It  is  really  the  repeated  traumatism 
of  a  mild  character  that  causes  the  trouble,  as  has  already  been  mentioned  under 
corset  and  belt  pressure.  I  believe  that  persons  who  suddenly  complain  of  pain 
in  the  loin  after  a  shock,  a  car  accident  or  jar,  and  in  whom  a  movable  kidney 
is  found  on  examination,  would  have  shown  the  presence  of  such  a  condition 
had  they  been,  examined  before  the  accident ;  but  as  there  was  no  reason  for 
such  an  examination,  the  presence  of  movable  kidney  naturally  was  not  known. 
On  the  other  hand,  when  a  movable  kidney  exists,  a  sudden  jar  or  wrench  may 
give  rise  to  renal  strangulation  and  thus  bring  on  symptoms  that  might  induce 
one  to  believe  that  the  mobility  had  been  caused  by  the  recent  traumatism. 

Heredity  is  spoken  of  as  a  predisposing  cause  of  abnormal  renal  mobility. 
This  may  be  true  in  a  way,  on  account  of  the  liability  of  the  child  to  .have  the 
same  body  configuration  as  the  mother,  and,  consequently,  if  the  mother  had 
a  movable  kidney,  the  child  would  be  predisposed  to  its  development,  for  I 
consider  the  body  form  as  the  principal  predisposing  factor  in  this  condition 
and  all  others  as  slowly  contributing  causes. 

The  Body  Index  in  Patients  with  ]\rovABLE  Kidney. — Bechcr  and 
Lennhof,  in  examining  a  large  number  of  Avomen,  found  that  they  could  gen- 
erally jndge  from  the  appearance  of  the  patient's  figTire  whether  one  of  the 
kidneys  was  palpable  or  not.  After  reasoning  out  the  whys  and  wherefores 
of  this  decision,  they  made  the  following  scientific  observation  and  deduction: 
First,  that  more  movable  kidneys  were  found  in  women  with  a  long  distance 
from  the  suprasternal  notch  to  the  pubes  and  a  small  waist  than  in  women  with 
a  short  trunk  and  large  waist ;  second,  they  decided,  after  taking  many  careful 
measurements,  that  the  distance  from  the  suprasternal  notch  to  the  upper 
margin  of  the  symphysis  pubes,  divided  by  the  smallest  circumference  of  the 
abdomen  and  multiplied  by  100,  constitutes  a  body  index.     Given  as  a  result 


ETIOLOGY  407 

or  quotient  75,  representing  llie  normal  woman,  if  a  niiml)er  above  this  resulted, 
say  77  to  80,  it  could  be  considered  positive  that  one;  kidney  was  movable; 
-whereas,  if  it  was  below  75,  say  7-}  or  less,  no  moval)lc  kidney  was  present.  The 
measurements  were  computed  according  to  the  metric  system  in  centimeters. 

,1         .•     1-    1  Jugulo-pubic  distance      .,...,,      J  ^-,    ,  •,• 

The  mathematical  mdex  =  ^r^. —     ,     ^-r-j X 100  =  ^  77-plus— positive 

Circumierence  01  abdomen  \ -^     .  ,. 

L7d-mmus — negative 

Harris,  of  Chicago,  continued  the  studies  of  Becher  and  Lennhof,  but  went 
into  the  subject  more  carefully,  and  has,  therefore,  been  able  to  give  to  the  pro- 
fession a  clearer  and  more  comprehensive  idea  of  the  importance  of  the  body 
form  ill  movable  kidney,  as  well  as  to  depict  the  shape  of  the  individual  predis- 
posed to  movable  kidney,  in  contradistinction  to  one  who  is  not  so  predisposed. 

Harris  divides  the  body  into  three  zones — the  upper,  middle  and  lower — 
by  drawing  three  planes  through  the  body  transversely.  (See  Fig.  272.)  He 
takes  the  tips  of  the  tenth  ribs  as  the  landmarks,  because  they  are  fixed  points, 
whereas  the  smallest  circumference  of  the  body  is  rather  an  uncertain  location. 
He  then  proceeds  to  take  certain  measurements  with  the  patient  lying  flat  on 
the  back.  The  circumference  of  the  body  at  the  tips  of  the  tenth  ribs  is  first 
measured  and  a  mark  is  made  with  a  pencil  where  this  line  crosses  the  median 
line.  A  mark  is  also  made  at  the  lower  end  of  the  sternum  and  the  circum- 
ference is  taken  at  this  point  also.  The  breasts  must  be  drawn  up,  if  they  are 
in  the  way,  and  the  circumference  should  be  taken  at  the  end  of  the  ordinary 
respiration.  Finally  the  distance  between  the  upper  sternal  notch  and  the 
upper  margin  of  the  symphysis  is  taken,  and  a  line  drawn  between  these  two 
points,  upon  which  the  length  of  each  zone  is  noted.  These  measurements  give 
us  Harris's  Index  ISTo.  1,  which  is  simply  the  jugulo-symphysis,  divided  by 
the  circumference  at  the  tenth  rib  and  multiplied  by  100.  It  is  similar  to  that 
of  Becher  and  Lennhof,  but  it  is  more  accurate.  When  this  index  is  above 
77  or  78,  the  kidney  is  palpable ;  but  when  it  is  below  these  figures,  palpation 
is  negative. 

By  a  comparison  of  the  different  zones  in  cases  with  palpable  kidneys,  it 
was  found  that  the  increased  length  of  the  jugulo-symphysis  was  situated 
chiefly  in  the  middle  zone,  while  the  upper  and  lower  zones  remained  practically 
the  same.  In  negative  cases,  the  average  circumference  of  the  upper  end  of  the 
middle  zone  was  77.1  cm.,  and  of  the  lower  end  of  the  middle  zone,  09.5  cm. 
On  the  other  hand,  in  positive  cases,  the  upper  circumference  of  the  middle 
zone  was  73.46  cm.,  and  61.9  cm.  for  the  lower  circumference.  Thus,  there 
was  a  nuirked  contrast  between  the  positive  and  negative  cases  in  regard  to 
the  circumference  of  the  lower  end  of  the  middle  zone.  In  other  words,  the 
middle  zone  was  elongated  and  made  narrower,  especially  at  the  lower  end, 
whenever  the  kidney  was  palpable. 


408 


MOVABLE   KIDNEY 


Harris  found  that  there  were  still  certain  sources  of  error  in  this  method 
of  measurement.  In  taking  circumferences,  accurate  measurements  are  diffi- 
cult to  get  in  fat  subjects,  for  the  breasts  are  in  the  way,  though  pulled  up, 
and  there  is  a  certain  spreading  that  corresponds  to  the  lower  margins  of  the 
ribs  when  a  corj)iilent  woman  lies  on  her  back.     For  this  reason,  he  deter- 


FiG.  272. — Anterior  View  of  the  Body  Di- 
vided INTO  Three  Zones,  the  Upper,  Mid- 
dle AND  Lower,  Made  by  Drawing  Three 
Planes  through  the  Body  Transversely. 
The  normal  female  body  is  drawn  in  heavy 
black  lines.  The  imperfect  female  body  is 
drawn  in  dotted  lines  and  is  the  one  predis- 
posing to  movable  kidney.  These  outline  draw- 
ings show  the  lateral  diameters  of  the  body 
index  in  the  healthy  person  and  in  people  with 
movable  kidney,  as  determined  by  Harris. 


Fig.  273.  —  Side  View  of  the  Body  and  the 
Lines  Corresponding  to  the  Antero- pos- 
terior Diameters  of  the  Body  Index  as  De- 
termined BY  Harris.  Here,  also,  the  heavy 
black  lines  show  the  normal  person  and  the  dot- 
ted lines  the  one  predisposing  to  movable  kidney. 


mined  to  nse  calipers  and  measure 
diameters  instead  of  circumferences, 
and  have  the  patients  standing  during 
the  measurements  instead  of  lying  down.  In  this  way,  he  measured  five  diam- 
eters, which  gave  him  very  accnrately  the  body  form  of  the  patient. 

First  Diameter :  The  widest  or  upper  lateral  diameter.  This  is  taken  with 
the  calipers  resting  at  the  widest  point  of  a  plane  corresponding  to  the  lower  end 
of  the  sternum,  usually  on  the  seventh  ribs  (Fig.  272,  iSTo.  1). 

Second  Diameter:  The  middle  lateral  diameter.  This  is  the  greatest  dis- 
tance between  the  lower  edges  of  the  tenth  ribs  (Fig.  272,  'No.  2). 

Third  Diameter:  The  lower  lateral  diameter — the  widest  distance  between 
the  iliac  crests  (Fig.  272,  No.  3). 


J 


ETIOLOGY 


409 


Fourth  Diameter:  The  upper  antcru-postcrior  diameter;  from  the  lower  cud 
of  the  sternum  to  the  spinous  process  opposite  in  tlie  same  plane  as  the  upper 
lateral  diameter  (Fig.  273,  No.  4). 

Fifth  Diameter:  The  middle  antero-posterior  diameter;  from  the  median 
line  in  front  to  the  spinous  process  opposite  on  the  same  plane  as  the  middle 
lalcral  diameter   (Fig.   273,  Xo.   5). 

In  order  to  draw  conclusions  from  his  transverse  diameters,  he  divided 
the  middle  lateral  by  the  upper  lateral  diameter  and  multiplied  the  quotient 
by  100,  thns  obtaining  Index  'No.  2.  The  second  index  refers  entirely  to  the 
middle  zone  and  shows  the  relation  between  the  lateral  diameters  of  its  lower 
and  upper  ends,  or,  in  other  words,  the  amount  of  constriction  at  the  lower  end. 

Index  No.  2  arranged  as  a  mathematical  problem  is  solved  as  follows  and 
shows  one  of  many  results  that  may  be  obtained: 

Middle  lateral  diameter  ^  -,j^^  _  fTB. 23 — positive 
Upper  lateral  diameter  \85.26 — negative 

Furthermore,  all  cases  below  81.8  were  found  positive,  that  is,  with  mova- 
ble kidney,  while  all  cases  above  81.8  were  found  negative. 
In  detail,  the  measurements  of  the  diameters  were  as  follows : 


Average  upper  lateral  diameter 

Average  middle  lateral  diameter .... 

Average  lower  lateral  diameter 

Average  upper  antero-post.  diameter 
Average  middle  antero-post.  diameter 


In  Negative 
Cases. 


23  .62  cm. 
20.2      " 
28.7      " 
16.9      " 
15.67    " 


In  Positive  Cases 


23  .85  cm. 
17.44  " 
29.06  " 
17.03  " 
14.26  " 


Difference. 


0 .  23  cm.  Practically  same. 
2 .76  cm.  or  13  .6  per  cent. 
0 .  36  cm.  Practically  same. 
0.13  cm. 
1 .41  cm.  or  9  per  cent. 


The  difference  between  the  upper  lateral  and  the  middle  lateral  diameters, 
in  negative  cases,  was  3.4  cm.  or  14.4  per  cent,  and  the  difference  between 
the  upper  and  middle  antero-posterior  diameters  in  these  cases  was  1.23  cm. 
or  7.28  per  cent.  In  the  positive  cases,  the  difference  between  the  upper  and 
middle  lateral  diameters  was  6.41  cm.  or  27  per  cent,  while  between  the  u]i])er 
and  middle  antero-posterior  diameters  the  difference  in  these  cases  was  2.8  cm. 
or  17  per  cent. 

These  figures  show  that  the  middle  zone  diminishes  in  size  from  above 
dowiiward  nearly  100  per  cent  more  from  side  to  side,  and  140  per  cent  more 
from  before  backward,  in  the  positive  cases  than  in  the  negative.  This  means 
that  there  is  a  marked  diminution  in  the  capacity  of  the  middle  zone  in  the 
positive  cases  in  which  the  kidney  can  be  felt  and  this  diminution  grows  more 
marked  in  these  cases  as  we  advance  in  the  middle  zone  from  above  downward. 

As  the  upper  zone  remains  practically  the  same  in  the  two  classes  of  cases, 
any  lessening  in  the  capacity  of  the  middle  zone  must  result  in  a  crowding 
of  the  contents  of  this  space  downward — in  other  words,  a  greater  tendency  to 


410  MOVABLE   KIDNEY 

H  displaced  kidncj.  The  above  description  contains  the  essence  of  Harris's 
views  and  is  ])ractieal]y  liis  own  Avording  with  his  conclusions  from  the  study 
of  the  body  indexes  as  devised  by  him. 

The  two  figures,  one  of  the  normal  body  and  the  other  of  the  form  predis- 
posing to  movable  kidney,  were  drawn  by  Harris  and  presented  to  me  by  him. 
I  here  take  this  oj)portunity  to  state  that,  in  my  opinion,  the  careful  study  that 
Harris  has  made  of  cases  of  movable  kidney  has  done  more  to  make  clear  the 
predisposing  cause  of  this  disease  than  any  other  writings  on  the  subject. 

Symptoms. — In  many  instances  there  are  no  symptoms  in  a  case  of  movable 
kidney,  as  has  been  ascertained  frequently,  when  its  presence  was  accidentally 
discovered  during  a  physical  examination  for  some  other  reason  than  for  indi- 
cations of  movable  kidney.  Frequently  the  severity  of  the  symptoms  is  by  no 
means  dependent  upon  the  degree  of  mobility  of  the  organ,  as  a  slightly  movable 
kidney  may  cause  great  suffering,  while  another  may  be  markedly  movable  with- 
out giving  rise  to  any  signs. 

Clinically,  there  are  three  types  of  movable  kidney — first,  the  painful  or 
neuralgic ;  second,  the  neurasthenic ;  third,  the  dyspeptic- — according  to  the 
]n-edominant  symj^tom,  although  they  may  be  associated  in  different  degrees. 
Pain  was  j)resent  in  99  per  cent  of  the  cases  in  my  own  practice. 

Pain. — Pain  is  due  to  traction  on  the  nerve  plexuses  and  on  the  peritoneum 
or  other  organs  covered  by  the  peritoneum,  especially  if  adhesions  are  present. 
Its  character  is  generally  a  dull  ache,  either  constant  or  recurring,  and  accom- 
]ianied  by  a  sense  of  dragging  or  heaviness.  It  is  usually  situated  in  the  loin 
below  the  twelfth  rib  and  less  frequently  in  front  on  one  side  of  the  umbilicus, 
in  the  iliac  fossa  or  in  the  groin. 

Occasionally  there  are  acute,  paroxysmal  attacks  of  i^ain  that  come  on  sud- 
denly, starting  in  the  loin  and  radiating  along  the  ureter,  called  Dietl's  crisis, 
somewhat  similar  in  character  to  those  of  renal  calculus.  During  the  severe 
attacks,  there  may  be  muscular  rigidity  on  the  affected  side,  the  kidney  may  be 
found  enlarged  and  tender  from  acute  congestion,  and  the  urine  may  contain 
blood.  There  may  be  oliguria  at  times  followed  by  polyuria.  These  attacks 
usually  last  for  a  few  hours  and  sometimes  for  a  few  days.  They  are  due  to 
kinks  or  compression  of  the  ureter,  causing  an  increased  renal  tension  and 
resulting  in  variable  degrees  of  renal  retention  or  temporary  hydronephrosis 
(Fig.  271).  The  records  of  my  own  cases  show  that  of  those  having  pain  four- 
teen per  cent  had  attacks  occm-ring  from  every  few  days  to  every  few  months. 
The  history  of  the  attacks  of  pain  covered  a  period  of  from  four  months  to 
fourteen  years. 

In  three  per  cent  of  my  cases,  the  pain  began  suddenly  and  tlie  patients 
attributed  the  condition  to  some  movement  they  had  made  just  before  they  first 
noticed  the  pain.  In  one  case,  the  patient  stooped  over  to  pick  up  some 
clothes,  since  when  she  has  experienced  a  peculiar  sensation  in  her  ria'ht  loin 


SYMPTOMS  411 

and  has  had  occasional  pain  of  a  dull  dragging  character.  Another  woman 
iii'.st  felt  the  pain  conic  on  while  raising  an  awning,  since  when  she  has  had 
i(  whenever  she  docs  hard  work.  Of  course,  the  occurrence  of  the  first  ])ain 
coming  on  suddenly  during  some  particular  exertion  does  not  mean  that  this 
has  caused  the  trouble,  but  that  the  stage  of  mobility  had  been  reached  when 
any  movement  or  jar  might  favor  the  sudden  falling  of  the  kidney  or  a  ureteral 
kinking,  causing  a  sudden  pnll  on  the  renal  or  ovarian  plexuses. 

Attacks  of  pain  generally  increase  in  frequency,  and  sometimes  in  severity, 
as  the  case  progresses.  In  twenty  per  cent  of  my  cases,  the  pains  were  dull  in 
character.     The  abdomen  was  usually  relaxed. 

^Eiivous  Symptoms. — The  nervous  phenomena  of  movable  kidney  are 
sjioken  of  as  hysterical  and  neurasthenic.  Among  these  nervous  symptoms, 
which  differ  in  various  individuals,  are  irritability,  restlessness,  depression, 
languor,  palpitation,  vertigo,  a  feeling  of  pressure  in  the  head,  neuralgia,  loss 
of  flesh  and  appetite,  and  a  general  impairment  of  health.  The  nervous  pains 
are  generally  ncphralgic,  sciatic,  lumbar  or  intestinal,  and  sometimes  ovarian 
or  testicular. 

Gastko-intestinal  oe  Dyspeptic  Symptoms. — Symptoms  of  this  char- 
acter are  frequent.  Of  these,  indigestion  and  flatulency  are  most  common. 
jSText  in  order  are  constipation,  due  to  pressure  or  dragging  upon  the  colon, 
gastralgia,  nausea,  vomiting  and  other  symptoms  of  gastritis  during  attacks  of 
renal  strangulation.  Jaundice  from  duodenal  traction  or  compression  of  the 
bile  ducts,  or  tugging  on  the  hepatico-cluodenal  ligaments,  is  not  so  common  as 
often  assumed.  Symptoms  of  appendicitis  may  be  produced  as  the  result  of 
compression  of  the  superior  mesenteric  vessels,  and  the  congestion  of  the  vermi- 
form appendix  which  follows.  According  to  Edebohls,  this  tendency  to  appen- 
dicitis is  found  in  fifty  per  cent  of  women  suffering  from  a  movable  kidney. 

Among  other  symptoms,  are  weakness,  dizziness,  loss  of  appetite,  throbbing 
in  the  abdomen  on  the  affected  side,  headache  and  constipation.  Chills  and 
fever  have  occurred  in  a  few  cases,  associated  with  pyelitis  and  renal  re- 
tention. 

ChaeactePv,  of  Ukination  axd  the  Urine. — In  discussing  these  two  symp- 
toms, there  are  several  points  to  he  considered.  The  character  of  the  urination 
does  not  differ  much  from  normal,  an}''  deviation  depending  principally  on  the 
presence  or  absence  of  renal  retention  or  strangulation,  the  latter  of  wliidi  is  not 
common.  If  there  is  renal  retention,  a  temporary  hydronephrosis,  there  will 
be  a  diminished  amount  of  urine  passed,  or  oliguria,  Avhile  the  secretion  is 
retained  in  the  kidney;  but  when  the  kidney  returns  to  its  proper  position,  a 
larger  amount  of  nrine  will  be  voided,  which  is  s])okon  of  as  ^lolyuria. 

In  renal  strangulation,  there  is  a  diminished  amount  of  urine  during  the 
attack,  after  which  an  increased  amount  of  a  highly  colored  urine,  often  con- 
taining blood,  is  passed. 


412  MOVABLE    KIDNEY 

In  the  usual  case  of  movable  kidney,  the  urinary  hndings  are  slight,  if  any: 
a  low  specific  gravity,  a  very  slight  trace  of  albumin  and  an  occasional  hyaline 
cast,  or  sometimes  a  few  finely  granular  casts.  These  findings  are  due  to  the 
irritability  of  the  kidney  and  the  strain  on  both  organs  incident  to  the  irregu- 
larities of  the  renal  circulation  and  the  urinary  excretion. 

Edebohls,  in  operating  on  movable  kidneys  by  partially  decapsulating  the 
organs  and  fastening  them  to  the  abdominal  wall,  noticed,  in  cases  with  this 
variety  of  urine  which  closely  resembled  that  of  interstitial  nephritis,  that  the 
polyuria,  casts  and  albumen  gradually  disappeared  or  diminished.  He,  there- 
fore, reasoned  that,  if  people  with  movable  kidney  passed  the  same  urine  as 
patients  with  interstitial  nephritis,  movable  kidney  was  the  cause  of  interstitial 
nephritis;  and  furthermore,  if  the  interstitial  nephritis  associated  with  mov- 
able kidney  was  cured  by  partial  decapsulation,  then  any  case  of  chronic  nephri- 
tis could  be  cured  by  decapsulation,  as  it  gave  the  kidneys  a  chance  to  form 
a  collateral  circulation  with  the  abdominal  wall  or  with  the  fatty  capsule.  This 
was  the  line  of  reasoning  that  led  him  to  recommend  total  decapsulation  of  the 
kidney  as  an  operation  for  the  cure  of  chronic  Bright's  disease. 

Physical  Examination. — Very  few  practitioners  can  feel  a  movable  kidney 
unless  the  mobility  is  quite  marked,  as  they  have  not  sufficient  practice  in  renal 
palpation.  This  should  not,  however,  be  considered  a  reflection  on  their  diag- 
nostic ability,  as  I  have  seen  the  best  surgeons  and  internists  fail  to  detect  this 
condition  when  kidneys  were  movable  in  a  marked  degree.  Again,  I  myself  have 
sometimes  had  the  greatest  difficulty  in  locating  movable  kidneys,  the  movement 
of  which  the  patient  could  sometimes  feel  in  her  abdomen.  Such  difficulties 
occurred  principally  in  patients  with  a  large  abdomen,  either  from  distention 
or  from  thick  walls.  This  leads  me  to  state  that  the  principal  difficulties  in 
detecting  a  movable  kidney  are,  a  thick  abdominal  wall,  too  firm  pressure  on  the 
part  of  the  examiner,  and  an  unfavorable  position  on  the  part  of  the  patient. 

To  show  the  ease  with  which  one  can  detect  a  movable  kidney  at  times,  I  will 
relate  the  history  of  a  patient  whose  husband  said  she  was  suffering  from  indi- 
gestion and  hives,  and  that  she  at  that  time  had  an  attack  of  hives  on  her  abdo- 
men which  annoyed  her  considerably  and  for  which  condition  he  asked  me  to 
prescribe.  At  the  time  of  the  visit,  she  was  examined  standing,  with  her  skirts 
lowered  and  her  upper  garments  raised  in  such  a  way  as  to  expose  her  abdo- 
men, which  was  the  principal  seat  of  the  eruption.  I  at  once  saw  a  typical 
band  of  herpes  zoster  on  her  right  side  and,  moving  my  finger  lightly  across  it 
to  see  if  the  characteristic  vesicular  feel  was  present,  I  detected  a  kidney  beneath 
my  finger  tips  which  was  displaced  by  the  gentle  pressure  used  and  which  came 
back  against  them  again  when  the  pressure  was  removed.  Since  then  I  have 
seen  several  movable  kidneys  which  have  been  as  easily  demonstrated,  and  none 
of  which  I  would  have  been  able  to  detect  if  I  had  resorted  to  the  strong  pressure 
that  I  was  formerly  in  the  habit  of  using. 


DIAGNOSIS  413 

A  change  of  position  is  also  a  most  important  procedure.  Most  patients  are 
examined  lying  flat  on  their  backs  with  the  result  that,  unless  tlic  ki(hicy  is  held 
down  by  adhesions,  it  will  go  back  into  its  fossa;  and  as  this  fossa,  in  the  right 
loin,  has  in  front  and  on  its  side  the  liver  and  ribs,  it  is  extremely  difficult  to 
palpate  the  organ.  It  is,  therefore,  advisable  to  examine  the  patient  on  a  table, 
the  back  and  shoulder  part  of  which  can  be  raised  so  as  to  allow  the  kidney  to 
fall  from  its  lodgment,  if  it  has  sufficient  mobility;  then,  having  made  firm 
pressure  below  the  lower  ribs  behind  and  in  front  on  that  side,  to  prevent  the 
kidney  from  slipping  np,  the  patient  should  be  lowered  into  the  dorsal  position 
again  while  keeping  her  abdominal  muscles  lax,  so  as  to  allow  the  examiner  to 
maintain  his  grasp  on  the  deeper  tissues  below  the  free  border  of  the  ribs. 

If  a  movable  kidney  has  been  prevented  from  returning  to  its  seat  in  this 
way,  it  is  held  down  by  one  hand  while  it  is  being  palpated  by  the  other.  If 
the  pressure  of  the  upper  hand  is  lessened  and  the  pressure  of  the  other  hand 
on  the  lower  border  of  the  kidney  is  increased,  it  will  be  felt  to  glide  up  under 
the  fingers  of  the  upper  hand  into  its  fossa.  A  kidney  can  often  be  felt  with 
the  patient  sitting  or  leaning  on  the  edge  of  a  table,  bed  or  chair,  without  the 
individual  being  lowered  into  the  recumbent  position.      (See  Fig.   234.) 

Frequently,  it  is  necessary,  in  order  to  palpate  the  kidney,  to  place  the  pa- 
tient upon  the  healthy  side,  in  a  reclining  posture,  with  the  shoulders  somewhat 
elevated  and  the  knees  slightly  flexed.  In  this  case,  it  will  also  tend  to  fall  out 
of  its  fossa  toward  the  healthy  side  of  the  abdomen.  Sometimes,  if  the  patient 
stands  with  the  buttocks  resting  against  a  table,  so  as  to  relax  the  abdomen,  this 
position  is  favorable  to  the  detection  of  movable  kidney  by  palpation. 

An  important  point  in  palpating  a  kidney  is  to  have  the  patient  take  a  long 
breath,  and  for  the  examiner  to  try  to  grasp  the  kidney  at  the  height  of  inspira- 
tion. The  surface  of  the  organ  is  usually  smooth,  though  sometimes  lobular, 
and  pressure  upon  it  occasionally  produces  nausea,  besides  which  it  is  frequently 
tender  to  the  touch. 

Percussion  has  been  of  little  value  to  me  and  so  has  inspection,  although  I 
have  seen  cases  where  the  contour  of  the  abdomen  was  changed  through  enlarge- 
ment of  the  kidney,  or  when,  together  with  a  loop  of  distended  colon,  it  exerted 
sufficient  pressure  on  one  side  of  the  anterior  wall  of  a  relaxed  abdomen  to  make 
it  more  prominent  than  on  the  opposite  side. 

Diagnosis. — Movable  kidney  is  at  times  difficult  to  diagnosticate.  A  cal- 
■culous  kidney  may  give  rise  to  attacks  of  renal  colic  closely  resendtling  the  pains 
of  movable  kidney  and  it  may  also  be  enlarged  and  have  a  certain  limited  ex- 
cursion. A  calculous  kidney,  however,  is  never  as  movable  and  is  usually 
harder.     X-ray  examination  may  show  the  presence  of  a  stone. 

Cases  of  hydronephrosis,  due  to  other  causes,  have  not  the  mobility  of  a 
movable  kidney.  Tumor  of  the  kidney,  while  it  may  reseudde  a  case  of  movable 
kidney  with  hydronephrosis,  is  associated  with  induration.     I  recently  had  a 


414  MOVABLE   KIDKEY 

case  of  renal  cancer,  in  which  iho  mass  was  freely  movahlo ;  in  fact,  the  pedicle 
was  so  adherent  to  the  peritoncniii  tliat  I  considered  it  a  niesonepbron.  It  is  a 
question  in  my  mind  whether,  in  this  particular  case,  the  weight  of  a  slow-i-Tow- 
ing  tnmor  produced  this  mobility,  or  whether  it  was  originally  a  movable  or 
floating  organ  which  was  the  predisposing  cause  of  the  growth.  I  know  frrmi 
exjierience  that  calculi  f(trm  in  the  pelvis  of  a  movable  kidney,  for  I  have  had 
such  cases  and  I  have  had  others  in  which  tuberculosis  developed.  I  can  under- 
stand also,  how  a  malignant  growth  might  develop  in  a  kidney  of  lessened  re- 
sistance. It  is  exceedingly  difficult,  however,  to  understand  the  develo])iiienr  of 
a  cancer  in  a  movable  kidney,  although  this  particular  case  that  I  have  just 
mentioned,  and  which  was  diagnosticated  as  such,  was  movable  from  the  renal 
fossa,  to  below  and  beyond  the  umbilicus  (T'ig.  204). 

Other  tiunors  of  the  alxlomen  do  not  reseml)le  movable  kidney  to  any  degree. 
I  have  never  seen  a  gall-bladder  that  could  be  mistaken  for  it;  neither  have 
I  seen  a  spleen  wdiich  I  have  mistaken  for  such  a  condition.  In  three  patients 
with  displaced  and  movable  liver,  recently  on  my  surgical  service,  all  my  col- 
leagues in  the  hospital  considered  them  to  be  movable  or  displaced  kidneys.  I 
demonstrated  to  them,  however,  that  such  w^as  not  the  case  and  that  although 
movable  kidneys  did  exist,  which  I  anchored,  the  livers  still  remained  in  the 
positions  in  which  they  were  at  the  time  of  the  examination. 

Regarding  the  tumors  and  cysts  of  the  ovary  and  uterine  tumors,  I  will  say 
that  I  have  never  seen  an  ovarian  tumor  or  cyst  that  I  could  mistake  for  a  mov- 
able kidney.  In  fact,  in  tumors  of  the  pelvis,  the  direction  of  their  extension 
is  so  different — upward  instead  of  downward — and  the  bimanual  pal})ation 
differs  so  greatly,  that  I  have  never  foimd  any  difficulty ;  although  I  realize 
that  it  must  be  confusing  in  some  cases,  as  one  of  the  first  nephrectomies  that 
was  performed  was  one  in  which  a  kidney  was  removed  from  the  pelvis  by  mis- 
take, the  operator  considering  it  an  ovarian  cyst.  Tumors  of  the  uterus  that  are 
movable  have  their  mobility  in  the  pelvis,  or  in  the  lower  abdomen  rather  than 
the  upper.  Besides  this,  their  consistency  is  gTeater,  they  cannot  be  pushed  up 
into  the  renal  fossa  and  bimanual  palpation  would  show  them  to  be  wholly  or  in 
part  in  the  pelvis. 

In  case  the  symptoms  point  to  renal  calculus  or  movable  kidney.  X-ray  pic- 
tures should  always  be  taken,  as  it  is  occasionally  found  that  a  renal  calculus  is 
present  in  a  movable  kidney.  It  may  also  be  mistaken  for  renal  tuberculosis,  in 
which  case  a  search  for  the  bacilli  should  be  made  in  the  urine  and  guinea-pig 
inoculation  resorted  to.  The  course  of  the  two  affections  is,  however,  very  dif- 
ferent and  signs  of  constitutional  disturbance,  loss  of  weight  and  strength,  a 
septic  temperature  and  the  urine  findings  will  determine  the  presence  of  the 
more  rapidly  destructive  disease. 

Complications. — The  complications  are,  renal  strangulation,  already  men- 
tioned, hydronephrosis  and  pelvic  or  reno-pelvic  infection. 


TREATMENT 


415 


Prognosis. — Movable  kidney  lias  vei-y  little  inflneiice  on  longevity,  except  in 
cases  of  a  complication  in  Avliieli  the  function  of  the  organ  is  interfered  with 
or  the  patient's  general  condition  is  impaired.  The  severe  type  of  symptoms 
already  mentioned  is  usuall}'  relieved  hy  fixation  of  the  organ. 

Treatment. — Preventive  and  Palt.iative. — Under  preventive  treatment 
must  be  considered  the  varions  predisposing  canses  that  tend  to  bring  abont 
movable  kidney  or  increase  its  mobility.  These  are  tightly  laced  or  badly  shaped 
corsets,  high  heels,  or  any  clothes  held  np  by  tight  belts  or  bands  in  men  or 
Avomcn  who  do  heavy  work  by  lifting  and  bending.  Certain  exercises  should  l)e 
avoided,  such  as  horseback  riding  or  other  forms  of  exercise  which  tend  to  pull 
or  bring  a  strain  on  the  kidney.  Valuable  procednres  are :  A  well-fitted,  straight- 
front  corset  or  a  corset  waist  with  shonlder  straps  for  women ;  suspenders  for 
men;  exercise  which  develops  slowly  the  abdominal  muscles  and  those  of  the 
loin,  in  this  way  tending  to  increase  intra-abdominal  pressure  and  regulate  the 
movements  of  the  bowels.  Pregnant  women  should  wear  well-fitted  abdominal 
belts  or  supports  during  the  last  month,  especially  if  they  have  a  flabby  abdo- 
men, and  should  also  wear  a  similar  support  after  childbirth  when  they  are  up 
and  abont  again.   They  should  be  careful,  however,  not  to  leave  the  bed  too  early. 

Palliative  treatment  includes  rest  in  bed,  a  liberal  diet,  massage,  electricity, 
abdominal  supports  and  the  remedies  which  relieve  pain  during  acute  attacks. 
Rest  in  bed  is  indicated  for  women  with  nervons,  neuralgic  and  mildly  painful 
symptoms.  The  Weir-Mitchell  cure  is  valuable  in  these  cases,  as  it  helps  to 
restore  the  nervous  balance.  Dr.  Weir-Mitchell  recommends  a  liberal  diet,  by 
which  is  meant  a  simple  but  nourishing  one,  such  as  eggs,  roast  meats — mutton, 
lamb,  beef  and  chicken — fish,  green  vegetables,  rice,  cereals  and  cooked  fruits. 
Eggs  should  be  boiled  or  poached ;  the  fish,  meats  and  poultry  boiled,  broiled  or 
roasted  and  the  vegetables  boiled.  Sweets  should  be  restricted  and  fried  foods 
altogether  forbidden.  In  addition  milk,  malt  extract  and  other  adjuncts  of  a 
milk  diet  can  be  used.  A  small  quan- 
tity of  coffee  in  the  morning,  and 
milk  and  black  coffee  after  dinner, 
are  allowed. 

Massage  is  a  valuable  means  of 
strengthening  the  abdominal  walls 
and  loins,  and  should  be  employed 
for  from  twenty  to  forty  minutes 
daily.  In  this  procedure,  the  aim 
should  be  not  to  reach  the  kidney,  but  simply  to  strengthen  the  abdomen.  It 
should  never  be  given  sooner  than  one  hour  after  meals.  Electricity,  with  the 
faradic  or  high-frequency  current,  is  also  of  value. 

Abdominal  supports  are  a])pliances  which  tend  to  press  the  abdominal  wall 
and  its  contents  upward  from  the  pubes  (Fig.  27-1).     They  are  made  of  elastic 


Fig.  274. — Pomeroy'-s  Elastic  Abdominal  Sup- 
port FOR  Patients  with.  Movable  Kidney. 


416 


MOVABLE   KIDNEY 


webbing',  similar  to  elcistic  stockings,  and  arc  laced  in  tlie  back.  :\Iany  palicnts 
require  perineal  bands  passing-  between  tlie  thighs  to  hohl  them  in  phicc. 
Straight-fnmt  corsets   (Van  Orden),  if  carefnlly  constructed,  are  valiiahle  as 


Fig.  275.— Straight-front       Fig.  276.— How  the  Corset  Should  be  Put  on  in  Movable  Kidney- 
Corset    for    Movable  (Gallant's  method.) 

Kidney.     (Van  Orden.) 


.. 

_^  ^" 

~~~-^-.      ^ 

^ 
^ 

X 

X 

/^                                    ^ 

B 

N. 

/" 

V 

y 

^^ 

Fig.  277A. — Wide  Strips  op  Adhesive  Plaster  for  Supporting  the  Abdomen. 


TREATMENT 


417 


a  simple  and  practieal  alxlominal  .siip])ort  (Fig.  275).  Gallant  makes  a  special 
point  of  the  manner  of  jiiitting  on  a  straigiit-front  corset  in  women.  This  should 
be  done  while  she  is  lying  on  the  back  with  the  pelvis  elevated ;  the  corset  is 
hooked  first  at  the  lowest  part  over  the  piibes,  after  which  the  remaining  hooks 
are  adjnsted  from  below  npward  (Fig.  276).  Straight-front  cor.sets  have  ;the 
advantage  at  present  of  being  fashionable,  as  well  as  improving  the  figures  of 
women.  It  is  well  to  wear  a  thin  cloth  band  under  tliese  elastic  supports.  Wide 
strips  of  adhesive  plaster  can  also  be  applied  for  abdominal  support  (Fig.  277, 
A,  B).  Abdominal  exercises  are, 
however,  of  the  greatest  importance, 
as,  by  developing  the  muscles  of  the 
abdomen,  they  act  as  a  straight-front 
corset.  (See  chapter  on  Exercise  in 
Urology. ) 

In  painful  conditions,  accom- 
panying strangulation  of  the  kidney 
in  DietFs  crises,  the  patient  should 
be  treated  as  in  renal  colic,  by  anal- 
gesic remedies,  such  as  morphin, 
bromids,  aspirin,  antipyrin,  or  hot 
applications,  besides  any  other  meas- 
ures that  seem  to  be  indicated.  If 
none  of  the  palliative  remedies  give 
relief  and  if  the  patient's  general 
condition  sufi"ers,  or  if  a  complica- 
tion such  as  painful  colic  or  Dietl's 
crises  takes  place  with  increased  frequency,  a  fixation  of  the  kidney  should  be 
recommended,  on  the  ground  that  it  is  better  to  undergo  the  trials  of  an  opera- 
tion than  to  continue  to  put  up  with  the  continued  inconvenience  and  ])oor 
health  connected  with  a  bad  moval)le  kidney. 

If  hydronephrosis  is  present,  fixation  of  the  kidney  should  be  urged  as  a 
necessary  procedure ;  whereas,  in  those  cases  in  which  movable  kidney  is  com- 
plicated by  a  malignant  tumor,  tuberculosis,  or  advanced  pyonephrosis,  nephrec- 
tomy should  be  performed.  If  a  calculus  is  present,  a  nephrotomy  for  its  re- 
moval and  subse(iuent  fixation  of  the  organ  is  indicated. 

Nephrectomy  for  the  cure  of  an  uncomplicated  movable  kidney  should  never 
be  ]xu'formed.  In  forty-two  such  operations  reported  by  Wagner,  eleven  died, 
making  a  mortality  of  nearly  twenty-five  per  cent. 


Fig.  2775.- 


■The  Adhesive  Plaster  Strips 
Applied. 


CHAPTER    XXIII 

NONSUPPURATIVE   NEPHRITIS 

(Br i gilt's  Disease  of  the  Kidneys) 

The  term  Briglit's  disease  lias  given  rise  to  so  much  confusion  that,  Avere  it 
not  for  its  long  usage,  it  Avould  be  advisable  to  drop  the  name. 

Very  little  i\'as  known  concerning  the  diseases  of  the  kidneys  until  1827, 
when  Bright  published  the  histories  of  some  cases  of  dropsy  with  albuminuria, 
together  with  the  autopsy  records  showing  the  presence  of  various  kidney  lesions. 
From  the  study  of  these  cases,  he  concluded  that  disease  of  the  kidney  was  asso- 
ciated with  dropsy  and  albuminuria,  and  the  name  Bright's  disease  was  given 
to  kidney  diseases  with  these  symptoms. 

Wilkes,  in  1853,  described  definitely  two  forms  of  Bright's  disease  as  nephri- 
tis— the  interstitial  and  parenchymatous — although  he  admitted  that  a  mixture 
of  the  two,  forming  a  third  tyjie — the  diffuse — might  also  occur. 

Virchow,  in  1871,  described  three  forms  of  Bright's  disease:  That  aris- 
ing from  the  vessels  (the  amyloid  form),  that  originating  from  the  epi- 
thelia  (the  parenchymatous  form)  and  that  developing  from  the  interstitial 
tissue ;  but  he  also  emphasized  that  the  three  forms  do  not  always  occur  singly, 
but  two,  or  even  all  three  types,  are  seen  frequently  in  the  same  kidney. 

In  1879,  Weigert  published  studies  which  are  practically  the  foundation 
of  the  modern  view  of  Bright's  disease.  He  claimed  that  there  Avas  no  such 
thing  as  a  parenchymatous  nephritis  Avithout  interstitial  changes,  nor  was  there 
an  interstitial  nephritis  Avithout  epithelial  changes.  He  shoAved  that  the  many 
varieties  of  kidney,  small  and  large,  Avhite,  red  and  mottled,  which  Avere  found 
at  autopsies  and  AAdiich  AA-ere  made  the  basis  of  different  classifications,  in  reality 
depend  upon  quantitative  differences  in  the  amount  of  congestion,  of  edema,  of 
fatty  degeneration  and  of  interstitial  changes. 

Brault  taught  that  the  best  division  Avas,  first,  acute  and  chronic  nephritis; 
acute  nephritis,  to  be  subdivided  into  transient  acute,  hyperacute  and  subacute ; 
and  chronic  nephritis,  to  be  subdivided  into  nephritis  with  dropsy  and  nephritis 
with  uremia. 

Since  the  time  of  Weigert,  the  classifications  of  nephritis,  etiologically, 
pathologically  and  symptomatically,  haA^e  included  hundreds  of  names,  so  that 
418 


ACUTE   NEPHEITIS  419 

we  are  pleased  to  see  in  the  latest  book  on  the  snLject,  by  Chauffard,  that  the 
old  terms  "  acute  nephritis  "  and  "  chronic  parenchymatous,  interstitial  and 
diffuse  "  are  still  considered.  This  will,  therefore,  be  the  classification  fol- 
lowed in  this  chapter.  The  terms  dropsical  and  uremic  nephritis  will,  however, 
be  associated  with  the  names  parenchymatous  and  interstitial. 

ACUTE   NEPHRITIS 

Etiology. — Acute  nephritis  is  usually  caused  by  the  germs  giving  rise  to  in- 
fective disease  or  to  their  toxic  products.  The  most  important  of  these  diseases, 
are  scarlatina,  diphtheria,  pneumonia,  measles,  acute  articular  rheumatism, 
influenza,  typhoid,  malaria,  smallpox,  cholera,  yellow  fever ;  while  septicemia, 
erysipelas  and  chicken-pox  may  also  be  mentioned  as  causes.  The  germs  of 
pneumonia  and  typhoid  have  been  found  both  in  the  kidney  and  in  the  urine. 
In  diphtheria,  the  presence  of  the  toxin  has  been  fairly  well  demonstrated. 

Pregnancy  sometimes  gives  rise  to  an  acute  nephritis  of  toxic  origin,  as  a 
result  of  the  production  of  placental  toxins  passing  into  the  system  of  the 
mother,  that  are  not  properly  eliminated. 

Exposure  to  cold  is  a  frequent  and  most  important  cause  of  acute  nephritis 
which  is  but  imperfectly  understood.  According  to  Chauffard,  cold  tends  to 
increase  the  number  of  germs  circulating  in  the  blood  and  to  promote  the 
passage  of  germs  from  the  intestines  into  the  circulation.  The  nephritis  due 
to  cold,  may,  therefore,  after  all  be  of  infectious  origin. 

Poisons  taken  internally  may  cause  acute  nephritis,  such  as  turpentine,  can- 
tharides,  chloroform,  ether,  mercury,  sulphuric  and  oxalic  acids,  and  the  in- 
ternal or  external  use  of  carbolic  acid,  iodoform  and  tar.  Alcohol,  and  spices 
which  irritate  the  kidneys,  may  also  give  rise  to  acute  nephritis,  if  given  in 
large  doses.  Potassium  chlorate,  in  overdoses,  gives  rise  to  hemoglobinuria  and 
acute  nephritis.  Extensive  burns  and  chronic  skin  diseases  which  destroy  the 
function  of  large  areas  of  skin  are  also  among  the  causes. 

Pathology. — The  kidneys  in  acute  nephritis  are  usually  large,  heavy,  with 
tense  capsules  which  are  easily  peeled  off.  Their  surface  is  either  dark  red  or 
mottled  grayish-red  in  color,  occasionally  pale  and  gray.  An  incision  through 
the  convexity  into  the  pelvis  shows  that  their  tissues  are  rather  soft  and  friable, 
their  cortex  sw^ollen,  cloudy,  gray  and  yellow  and  their  medullary  portion  dark 
and  congested. 

Microscopically,  there  are  changes,  either  in  the  parenchyma  alone,  or  in  the 
interstitial  tissue  also. 

The  epithelia  of  the  convoluted  tubules  are  either  in  a  state  of  cloudy  swell- 
ing or  of  gTanular  and  fatty  degeneration.  At  times,  they  are  almost  completely 
destroyed  and  fill  the  lumen  of  the  canal.  Hyaline,  granular,  fatty  and  blood 
easts  are  found  in  the  tubules.     The  glomeruli  do  not  show  many  changes  in 


420  NONSUPPURATIVE    NEPHRITIS 

the  liiikler  cases,  save  an  exudation  of  allnuiiin  wiiliin  their  capsules;  in  tlie 
severe  cases,  their  capillaries  are  filled  with  blood,  sometimes  with  thrombi 
and  their  epithelia  are  degenerated  or  proliferated. 

If  the  interstitial  renal  tissue  is  also  involved,  it  is  the  seat  of  a  swelling  or 
edema  between  the  fillers.  The  vessels  are  engorged  and  their  walls  are  in  a 
state  of  acute  inflammation.  Hemorrhages  in  various  parts  of  the  kidney,  for 
example,  in  the  glomeruli,  the  tubules  or  the  connective  tissue,  ma}'  also  be 
found.  In  severe  forms,  a  small  cellular  infiltration  is  frequently  seen  in  the 
connective  tissue  about  the  capsules  of  the  glomeruli  and  between  the  tubules. 

The  inflammation  may  terminate  in  complete  resolution,  or  the  condition 
may  be  followed  by  a  chronic  nephritis. 

Symptoms. — Acute  nephritis  may  be  subdivided  clinically  into  (a)  acute 
transient,  (h)  hyperacute  and  (c)  subacute  or  prolonged  nephritis. 

(a)  The  acute-tkansiext  foem  includes  a  group  of  nephrites  occurring 
during  the  course  of  an  infectious  disease,  such  as  typhoid.  There  is  no  edema, 
nor  uremic  symptoms ;  the  amount  of  urine  is  increased,  albumin  is  considerable 
and  blood  slight.  The  sediment  contains  hyaline  and  gTanular  casts  and  a  few 
red  and  white  blood  cells. 

(h)  ITypekacute  Xepheitis. — This  is  the  result  of  violent  poisoning  with 
biclilorid  of  mercury,  phosphorus,  cantharides  and  other  drugs  causing  great 
renal  irritation^  or  it  may  develop  in  the  course  of  acute  infectious  diseases,  as 
scarlet  fever  or  diphtheria.  The  chief  characteristic  of  this  type  is  the  rapidly 
increasing  anuria,  which  is  one  of  the  earliest  symptoms.  It  may  occur  within 
a  few  hours  after  taking  one  of  the  poisons  mentioned  and  frequently  terminates 
.suddenly  in  death.  There  are  no  major  symptoms,  such  as  edema  or  uremia. 
Recovery  from  this  form  of  toxic  nephritis  is  rare  and  occurs  principally  in 
cases  following  an  infectious  disease. 

(c)  The  srBACUTE  or  protracted  is  the  most  common  clinical  type  of  acute 
nephritis,  and  its  course  will  be  princiiDally  considered.  It  is  usually  the 
result  of  acute  infection  or  intoxication^  although  it  may  be  due  to  cold.  The 
nephritis  due  to  cold  and  that  due  to  scarlet  fever  and  diphtheria  are,  perhaps, 
the  most  typical  representatives  of  this  group. 

In  both  instances,  the  urine  is  dark  in  color,  or  even  reddish,  the  sjiecific 
gravity  is  high,  the  reaction  markedly  acid.  The  urea  and  the  chlorids  are 
lessened.  There  is  always  a  considerable  amount  of  allunnin,  two  or  three  grams 
per  liter.  Under  the  microscope,  the  sediment  shows  finely  and  coarsely  granu- 
lar epithelial  and  blood  casts,  red  blood  cells,  leucocytes  and  renal  epithelia, 
some  of  which  are  in  a  state  of  fatty  degeneration. 

Their  general  course  in  the  later  stages,  especially  in  severe  cases,  is  about 
the  same,  although  their  onset  may  he  different. 

In  nephritis  due  to  cold,  which  is  also  called  neplnilis  a  fiigore,  the  onset  is 
usually  accompanied  by  violent  pains  in  the  back  and  loins,  a  sudden  rise  of 


ACUTE   NEPHRITIS  421 

temperature  to  101°  F.  or  more,  and  a  ])iilse  of  aljout  100  ;  vomiting  often  occurs 
at  the  onset. 

An  exaiiiiiKitinu  of  tlie  jiatient  at  this  time  nsnally  shows  tenderness  on 
pressure  over  the  kidneys,  and  the  or<2;ans  may  be  felt  to  be  enhiriie(L  Edema 
then  shows  itself,  nsually  as  a  white  puffiness  of  the  face,  especially  about  the 
eyelids  and  over  the  sternum  and  later  about  the  ankles.  The  acnte  process  may 
not  extend  beyond  this  stage.  In  severe  cases,  the  edema  increases  in  the  lower 
extremities,  and  the  pleura,  the  pericardial  and  peritoneal  cavities  may  Ijecome 
involved.  Subcrepitant  rales  may  also  be  heard  on  auscultation,  showing  that 
an  edema  of  the  lungs  is  imijending.  These  involvements  wall  give  rise  to  more 
or  less  dyspnea.  In  bad  cases,  symptoms  of  uremia  may  now  begin,  in  which 
case  there  will  be  a  diminished  amount  of  nrine,  headache,  disturbance  of  sight 
and  hearing,  and  perhaps  vomiting  and  diarrhea  may  develop.  If  the  nremic 
condition  increases,  the  tongue  will  become  dry  and  coated,  and  delirium  or 
convulsions  may  set  in,  followed  by  coma  and  death.  The  symptoms  that  I  have 
described  may  all  be  present  in  a  given  case,  or  only  a  few  of  them ;  they  may 
occur  somewhat  in  the  order  that  I  have  described  or  very  differently.  The 
nephritis  may  stop  at  any  point  in  this  list  of  symptoms  and  the  patient  re- 
cover. The  symptoms  of  an  accumulation  of  fluid  in  the  serous  cavities  and  an 
edema  of  the  lungs  are  very  serious,  while  edema  of  the  glottis  in  itself  is 
very  dangerous.  Albuminuric  retinitis  forebodes  a  fatal  outcome ;  convul- 
sions are  very  alarming;  and  a  dry  tongue,  delirium  and  coma  point  to  a  fatal 
issue. 

Scarlatinous  nepliritls,  representing  the  type  of  acute  nephritis  complicat- 
ing scarlet  fever,  diphtheria  and  other  infectious  diseases,  occurs  during  the 
period  of  defervescence.  The  symptoms  of  the  onset  may  be  the  same  as  those 
just  enumerated  in  connection  with  nephritis  a  frigore.  Usually,  however,  albu- 
minuria is  the  only  symptom  noted.  On  the  other  hand,  the  first  symptoms  may 
be  severe,  as  edema  may  set  in  and  rapidly  become  a  general  anasarca ;  whereas, 
other  cases  may  be  characterized  by  uremic  symptoms.  The  later  symptoms 
Avill  be  similar  to  those  mentioned  under  Nephritis  Due  to  Cold.  It  is,  on  the 
whole,  the  graver  of  the  forms  of  protracted  acute  nephritis. 

In  either  of  the  varieties  under  consideration,  an  increased  flow  of  urine 
and  an  increased  activity  of  the  skin,  as  sho^^^l  by  sweating,  may  come  at  any 
time  during  the  disease,  and  recovery  take  place ;  or  the  synipt(uns  will  disaj> 
]t('ar,  with  the  exco])ti(m  of  some  albumin  and  casts  in  the  urine,  in  which  case 
the  disease  usually  becomes  chronic. 

Generally,  the  attacks  of  subacute  nephritis  do  not  reach  the  stage  in  which 
the  serous  cavities  become  involved,  or  in  which  there  are  marked  uremic  symp- 
toms. The  active  stage  of  the  attack  usually  lasts  for  three  weeks,  during 
Avhich  time  the  temperature  is  but  slight  or  ranges  from  90°  to  101°  F.,  with 
a  pulse  of  from  90  to  100.     If  these  gradually  subside,  the  patient  will  prob- 


422  NONSUPPURATIVE    NEPHRITIS 

ably  recover  by  the  end  of  six  or  eight  weeks,  or  else  pass  into  ihe  chronic  stage. 
The  blood  pressure  in  acute  nephritis  is  from  130  to  150. 

Diagnosis. — Acute  nephritis  occurring  in  the  course  of  an  infectious  dis- 
ease will  not  be  overlooked  if  we  make  it  a  habit  to  examine  the  urine  for  albu- 
men in  every  case.  The  history  of  the  patient  will  show  us  whether  we  are 
dealing  with  an  acute  nephritis  or  wdth  an  exacerbation  of  a  chronic  condition. 
In  the  latter,  the  urine  shows  in  the  sediment  hyaline,  fatty  casts  and  fatty  or 
degenerated  renal  epithelia. 

There  is  also  a  history  of  a  previous  acute  nephritis,  or  an  infectious  disease. 
The  presence  of  thickened  arteries  and  of  hypertrophy  of  the  heart,  as  well  as 
changes  in  the  retina,  are  also  points  which  show  that  a  chronic  nephritis  has 
existed  for  some  time  and  is  now  in  an  acute  explosion. 

The  diagnosis  between  renal  hemorrhages  from  other  causes  and  an  acute 
nephritis  with  bloody  urine  is  not  difficult.  In  the  latter,  the  urine  is  dimin- 
ished in  amount  and  contains  renal  epithelia,  leucocytes  and  hyaline,  granular 
and  epithelial  casts.  The  presence  of  fever  and  edema  are  also  signs  which 
help  to  differentiate  the  condition  from  renal  hemorrhage.  In  renal  hemorrhage 
due  to  tumor,  atypical  cells  and  tumor  fragments  would  be  found  in  the  urine. 
If  due  to  stone,  crystals  would  be  present,  and  if  due  to  tuberculosis,  tubercle 
bacilli.     The  treatment  of  acute  nejohritis  wall  be  considered  later. 

CHRONIC  NEPHRITIS 

As  we  remarked  in  the  introductory  chapters,  the  terms  chronic  paren- 
chymatous and  chronic  interstitial  nephritis  are  no  longer  regarded  wdth  favor 
•by  some  modern  clinicians.  What  was  formerly  known  as  chronic  paren- 
chymatous nephritis  some  now  style  chronic  nephritis  Avith  dropsy,  and  what 
was  known  as  chronic  interstitial  nephritis,  they  call  chronic  nephritis  wdth 
uremia.  However  clinicians  may  call  these  two  general  groups,  the  autopsy 
findings  show  that,  although  in  all  cases  of  chronic  nephritis  there  is  more  or 
less  evidence  of  both  parenchymatous  and  interstitial  changes,  the  preponder- 
ance of  the  disease  is  either  in  the  parenchyma  or  the  stroma.  In  comparing 
the  autopsy  findings  with  the  clinical  symptoms  during  life,  it  is  usually  found 
that  the  cases  accompanied  by  dropsy  are  of  the  parenchymatous  type  and  those 
accompanied  by  uremic  symptoms  are  of  the  interstitial  type. 

Chronic  PARENCiiYiiAxous  iSTEPiiKiTis 
{Chronic  Nephritis  iviih  Dropsy) 

Etiology  and  Pathogenesis. — This  form  of  chronic  nephritis  frequently 
follows  an  acute  or  subacute  renal  parenchymatous  inflammation,  or  it  may  also 
develop  wdthout  discoverable  reason.  In  the  latter  case,  the  real  cause  of  the 
chronic  nephritis  is  not  known,  but  it  is  supposed  to  lie  in  some  toxic  influence 


CHRONIC    NEPHRITIS  423 

Avhich  acts  upon  the  kidney  through  the  blood.  A  variety  of  causes  contribute 
more  or  less  distinctly  to  its  development.  Of  these,  we  may  mention  frequent 
or  protracted  exposure  to  cold  or  dampness  ;  overnutrition  ;  undernutrition ;  per- 
haps abuse  of  alcohol ;  various  constitutional  diseases,  such  as  tuberculosis, 
syphilis,  gout  and  chronic  malaria ;  diseases  of  the  heart,  especially  ulcerative 
endocarditis ;  and  chronic  poisoning  with  lead  or  mercury.  Chronic  paren- 
chymatous nephritis  may  also  be  the  result  of  a  previous  acute  infection  or  in- 
toxication, which  was  apparently  cured  and  reappeared  afterwards  in  this 
chronic  form.  Among  the  predisposing  causes  are  unfavorable  hygienic  sur- 
roundings, overwork  and  severe  physical  strain. 

Pathology. — U^^on  gross  examination,  the  kidneys  are  generally  enlarged 
and  the  capsule  is  adherent  in  places.  The  consistence  of  the  kidney  may  vary 
greatly.  The  surface  of  the  organ  is  pale  white  or  mottled.  An  incision  through 
the  convexity  shows  the  cortex  to  be  narrower  than  normal,  the  yellow  and 
white  finely  striated  markings  obscured.  The  medulla  is  not  much  changed. 
The  medullary  rays  are  slightly  darker  than  normal. 

The  lesions  in  this  type  of  nephritis  are  always  scattered  through  the  kidney 
in  patches  or  foci,  and  the  appearance  of  the  organ  depends  upon  the  arrange- 
ment of  these  foci  and  the  amount  of  changes  in  the  parenchymatous  and  in  the 
interstitial  tissues.  What  is  known  as  the  large  white  kidney,  for  example,  is 
a  parenchymatous  or  a  diffuse  nephritis  mixed  with  amyloid  kidney  (Senator). 
It  is  characterized  especially  by  fatty  degeneration  of  the  tubules  and  the 
glomeruli,  and  fibrous  and  hyaline  changes  in  the  stroma. 

The  large  mottled  kidney  is  the  result  of  lesions  in  patches,  involving  both 
the  parenchyma  and  the  stroma.  The  minute  hemorrhages  and  venous  conges- 
tion in  the  cortex  give  rise  to  the  mottled  appearance. 

Microscopically,  it  has  been  found  that  all  these  differences  depend  npon 
quantitative  relations  of  the  pathological  changes  in  the  various  classes  of  tissues 
of  the  organ  (Senator).  The  j)athological  changes  in  parenchpnatous  nephritis 
are  found  principally  in  the  cortex,  especially  in  the  epithelia  of  the  convo- 
luted tubules  and  less  frequently  of  the  straight  tubules.  These  epithelia  are  in 
various  stages  of  degeneration,  from  cloudy  swelling  to  complete  molecular 
necrosis,  and  are  shed  more  or  less  freely  into  the  lumen  of  the  tubules,  which 
contain  also  leucocytes,  fat  globules,  red  blood  cells  and  hyaline,  fine  or  coarse 
granular,  epithelial,  fatty  and  mixed  casts. 

While  the  type  is  known  as  the  parenchymatous,  there  are  always  some 
changes  in  the  interstitial  tissue  (diffuse  nephritis).  Foremost  of  these  is  an 
edema  of  the  stroma.  In  the  advanced  stages,  there  may  be  round-celled  infiltra- 
tion or  proliferation  of  the  interstitial  tissue  partly  clouding  the  parenchym- 
atous elements. 

The  glomeruli  are  also  affected,  showing  fatty  degeneration  and  necrosis  of 
their  epithelia,  and  an  exudate  within  their  capsules.     Their  capillaries  are  fre- 


424  NONSUPPURATIVE   NEPHRITIS 

queiitly  compressed  or  blocked  l)j  tlie  .swelling'  of  the  eiidothelia.  The  arterioles 
siirroinidiiiii,'  the  glomeruli  are  also  more  or  less  thickened. 

Symptoms. — The  symptomatology  of  chronic  parenchymatous  nephritis  is 
quite  clearly  defined.  There  may  be  a  prodromal  stage,  characterized  by  a 
fever  and  lumbar  pain,  but  usually  the  disease  sets  in  insidiously  with  slight 
and  transient  edema,  which  leads  to  an  examination  of  the  urine  and  to  the  dis- 
covery of  albumin  and  other  evidences  of  nephritis. 

The  edema  first  appears  on  the  lower  eyelids  or  on  the  face,  over  the  sternum 
or  at  the  ankles.  Later,  it  extends  to  the  legs,  the  scrotum,  the  abdomen,  the  loins 
and  the  rest  of  the  body,  after  which  the  edema  changes  its  place  according  to 
the  patient's  position.  It  is  greatest  in  the  legs  when  he  stands  and  greatest 
in  the  loins  and  buttocks  when  he  lies  in  bed  for  any  length  of  time.  Gradually, 
effusions  may  appear  also  in  the  pleura,  the  peritoneum  and  the  pericardium. 

The  extensive  edema  of  chronic  Bright's  disease  is  considered  by  some  as 
a  means  of  defense,  that  is,  that  the  toxins  which  are  not  eliminated  are  stored 
np  in  the  edematous  fluid  and  are  thus  kept  out  of  the  circulation.  This  theory 
is  proved  by  finding  toxic  constituents  in  serous  effusions  and  in  edematous 
fluids  in  chronic  nephritis. 

The  urine  in  this  form  of  chronic  nephritis  is  always  scanty,  clear,  of  high 
specific  gravity  and  straw  or  yellow  color.  The  toxins  of  the  urine  are  composed 
of  85  per  cent  of  inorganic  j^roducts,  the  princijDal  of  which  is  chlorid  of  potash, 
and  15  per  cent  of  unknown  organic  substances.  There  is  usually  a  considerable 
amount  of  albumin — over  2  grams  per  liter  (i  to  f  of  1  per  cent  by  weight). 
The  ordinary  urinary  salts  may  be  normal  or  increased,  save  the  chlorids,  which 
are  diminished.  Their  retention  in  the  system  when  the  kidneys  are  affected 
with  chronic  nephritis,  especially  in  the  parenchymatous  form,  has  been  thor- 
oughly demonstrated. 

Renal  epithelia,  numerous  fine  and  coarse  granular,  epithelial  and  fatty 
casts,  leucocytes  and  a  few  red  cells  are  found  in  the  sediment  of  the  urine. 

Cardio-vascular  symptoms  are  not  pronounced  in  this  form  of  nephritis. 
There  may  be  at  the  start  slight  weakness  of  the  heart  beats ;  the  arterial  tension 
may  be  at  first  slightly  lowered.  If  the  nephritis  turns  toward  the  chronic 
atrophy  or  interstitial  form,  we  note  a  rise  of  blood  pressure  and  a  marked  hyi^er- 
troph}^'of  the  left  ventricle. 

Course. — The  course  of  the  disease  in  this  type  of  nephritis  may  be  either 
rapid  or  slow.  If  it  is  rapid,  there  is  a  steady  increase  in  the  edema  and  a 
decrease  in  the  amount  of  urine  secreted.  The  heart  becomes  seriously  affected, 
the  pulse  feeble  and  rapid.  Gradually,  the  other  internal  organs  are  involved. 
The  appetite  fails,  the  tongue  becomes  coated,  the  breath  fetid.  There  are 
often  attacks  of  diarrhea  and  vomiting.  These  symptoms,  according  to  some 
writers,  are  due  to  the  invasion  of  the  gastric  walls  by  edema.  The  serous 
cavities  are  next  attacked  and  the  edema  spreads,  giving  rise  to  a  hvdrothorax. 


I 


CHRONIC    NEPHEITIS  425 

When  hydrocardiiiiii  develops,  wc  find  u  diffused  apex  beat,  dyspnea  and  a  tend- 
ency to  syncope.     'J'lic  blood  pressure  is  variable. 

These  i)atients  with  their  tense,  swollen  skin,  which  is  white  and  dry, 
present  a  characteristic  appearance.  In  fatal  cases,  if  death  is  not  due  to  an 
intercurrent  infection,  as,  for  instance,  a  broncho-pneumonia,  it  is  the  result  of 
gradual  exhaustion  and  finally  edema  of  the  lungs  or  uremia  after  a  hopeless 
period  of  disability. 

When  the  course  of  the  disease  is  slow  in  evolution,  the  edemas  are  much 
more  gradual  in  their  development.  The  patients  are  often  pale,  puffy,  with 
a  peculiar  luster  of  the  eyes  (edema  of  the  conjunctiva)  and  at  times  complain 
of  headaches  and  other  minor  uremic  signs. 

Diagnosis. — The  diag-nosis  of  chronic  parenchymatous  nephritis  is  generally 
not  difficult,  as  edema,  pallor  and  abundant  albuminuria  are  usually  well 
marked.  It  is  distinguished  from  acute  nephritis  (or  from  an  acute  exacerba- 
tion of  a  chronic  nephritis)  by  the  history  of  the  case  and  by  the  absence  of 
acute  symptoms,  such  as  fever  and  blood  and  blood  casts  in  the  urine.  It  is  at 
times  not  easily  distinguished  from  amyloid  kidney,  as  amyloid  changes  may 
exist  with  such  a  nephritis.  The  diagnosis  of  an  amyloid  kidney  can  only  be 
made  when  there  is  an  amyloid  enlargement  of  other  organs  and  when  there 
is  a  history  of  some  cause  for  an  amyloid  kidney.  In  amyloid  kidney  the 
quantity  of  urine  is  large  and  the  color  pale,  although  there  may  be  large 
amounts  of  albumin.  We  should,  therefore,  suspect  an  amyloid  degeneration 
whenever  the  amount  of  albumin  in  a  chronic  case  tends  to  exceed  ten  or  twelve 
grams  in  twenty-four  hours.  In  amyloid  kidneys,  the  urine  does  not  contain 
granular  casts,  save  in  the  very  advanced  cases. 

Diffuse  ISTepiikitis 

This  represents  the  case  of  chronic  parenchymatous  nephritis  with  cardiac 
and  vascular  changes,  which  start  as  a  typically  parenchymatous  type  but  go  on 
sloMdy  toward  the  atrophic  or  interstitial  form.  The  urine  in  these  cases  is 
more  abundant  than  in  the  pure  parenchymatous,  lighter  in  color,  Avith  a  lower 
specific  gravity  and  contains  a  smaller  amount  of  albumin. 

As  the  disease  progresses,  and  as  the  heart  hypertrophies  and  the  artcM-inl 
tension  increases,  the  edemas  grow  less  marked,  but  what  appears  like  an  im- 
provement is  in  reality  a  transition  to  the  interstitial  form. 

Chronic  Interstitial  I^epiiritis 

Etiology. — The  development  of  this  disease  must  be  referred  to  the  long- 
continued  action  of  slight  toxic  factors,  usually  of  a  systemic  origin.  Concern- 
ing the  relation  of  arteriosclerosis  to  this  form  of  nephritis,  arteriosclerosis  may 
be  the  cause  of  chronic  interstitial  nephritis,  or,  on  the  other  hand,  it  may  be 


426  no:n'suppurative  nephritis 

the  result  of  it,  Liit  it  is  ])rf)l)al)l('  that  more  often  both  arteriosclerosis  and 
chronic  interstitial  nephritis  are  the  result  of  the  same  causes,  such  as  chronic 
poisoning  with  lead,  alcohol,  gout  or  syphilis.  Diabetes  mellitus  may  also  be 
mentioned  as  the  cause  of  this  form  of  nephritis.  Senator  called  attention  to 
the  frequency  with  which  arteriosclerosis  and  the  accompanying  interstitial 
nephritis  is  met  with  in  diabetic  patients  of  advanced  age. 

From  what  has  been  said  concerning  the  causes  of  this  condition,  it  will  be 
understood  that  chronic  interstitial  nephritis  is  rare  in  childhood  and  youth, 
and  frequent  toward  the  end  of  life.  The  frequency  increases  with  the  age 
of  the  patient,  being  greatest  between  fifty  and  sixty.  Men  are  more  frequently 
aifected  than  women,  because  they  are  more  often  exposed  to  the  causes 
above  mentioned.  Occasionally,  there  is  an  hereditary  or  family  predis- 
position toward  this  disease.  The  condition  has  also  been  found  present  at 
birth. 

Pathology. — The  essential  pathological  change  in  this  form  of  nephritis  is 
a  slow  hypertrophy  of  the  interstitial  tissue,  stroma  of  the  kidney,  with  a  gTad- 
ual  disapi^earance  of  the  parenchyma.  The  appearance  of  the  kidney  varies 
with  the  duration  of  the  disease.  In  the  early  stages,  the  kidneys,  are  normal  in 
size  or  slightly  enlarged  and  mottled.  In  the  advanced  stage,  they  may  have 
shrunken  to  half  their  size  or  even  less,  one  kidney  being  usually  more  markedly 
affected  than  the  other.  The  capsule  is  generally  adherent  in  places  and  con- 
tains newly  formed  vessels.  The  surface  of  the  kidney  is  covered  with  minute 
red  or  grayish  elevations,  showing  sometimes  small  cysts  among  them.  On 
section,  the  kidneys  are  hard  and  tough,  their  cortex  shrunken,  sometimes  ap- 
pearing as  a  narrow  border  around  the  medulla.  The  medullary  rays  are  also 
shortened,  closely  packed  and  darker  in  color  than  normal.  The  visible  arteries 
show  thickened,  gaping  walls,  and  at  times  there  are  infarcts  of  uric  acid  or  of 
calcium  salts  in  the  renal  tissue. 

On  microscopical  examination,  the  changes  are  found  chiefly  in  the  cortex 
and  usually  are  scattered  in  patches.  The  interstitial  tissue  is  greatly  increased, 
with  here  and  there  some  round  cell  infiltrations.  The  tubules  are  compressed 
or  in  places  obliterated,  their  epithelia  are  in  a  state  of  atrophy  or  fatty  de- 
generation or  lying  loosely  detached  in  their  lumen. 

The  glomeruli  are  the  seat  of  a  cellular  proliferation  around  their  capsules, 
which  compress  them  and  render  them  incapable  of  functionating.  Their  loops 
show  increased  layers  of  cells,  or  else  a  degeneration  of  cells,  swelling  of  the 
epithelia  and  fatty  degeneration  of  the  same.  The  cavities  of  the  glomeruli  may 
be  the  seat  of  an  exudate  as  in  the  parenchymatous  form.  Characteristic  arterio- 
sclerotic changes  are  found  in  the  arteries  of  these  kidneys. 

Symptoms. — This  form  of  nephritis  has  always  a  very  slow  and  insidious 
onset,  and  the  lesions  usually  exist  for  years  before  the  condition  is  recognized. 
The  disease  may  be  divided  into  three  stages : 


CHRONIC   NEPHRITIS  427 

(1)  The  stage  of  compensation, 

(2)  The  cardiac  stage, 
(8)   The  uremic  stage. 

(1)  Stage  of  Compensation. — In  the  first  stage  of  the  disease,  there  is  a 
compensation  for  the  gradually  increasing  involvement  of  the  kidney.  The  sys- 
tem in  some  way  accommodates  itself  to  the  altered  conditions.  During  this 
stage,  there  are  two  classes  of  minor  symptoms  that  may  occur : 

(a)   Those  due  to  arterial  hypertension  and  those  due  to  uremic  intoxication. 

The  symj)toms  due  to  arterial  hypertension  are :  Swollen  and  twisted  tem- 
poral arteries ;  occasional  attacks  of  anesthesia  in  the  fingers ;  slight  attacks  of 
epistaxis ;  noises  in  the  ears  and  impaired  hearing ;  occasional  vertigo. 

Those  due  to  uremic  intoxication  are :  Headaches,  which  are  not  relieved 
by  drugs  but  disappear  with  rest  and  diet ;  paresthesia,  sensation  of  cold,  heat, 
formication ;  cramps  in  the  ankles  awakening  the  patient  at  night. 

(h)  The  urine  in  this  stage  of  the  disease  is  increased  in  quantity,  and  the 
patient  urinates  frequently.  The  urine  is  pale,  clear,  usually  below  1.010  in 
specific  gravity ;  the  total  solids  are  diminished.  There  is  either  no  albumin 
or  merely  a  trace. 

(2)  The  Cardiac  Stage. — During  the  cardiac  stage,  which  follows  that  of 
compensation,  the  system  begins  to  feel  the  effect  of  the  diseased  kidney.  The 
cardiac  symptoms  of  this  stage  consist  in  palpitation,  attacks  of  angina  pec- 
toris, an  increase  of  arterial  tension,  hypertrophy  of  the  heart  and  a  hruit  de 
galop  (galloping  sound)  which  is  a  marked  uremic  symptom. 

Complications  may  set  in  during  this  stage,  some  of  which  may  prove  fatal 
before  it  has  fully  developed,  such  as  hemorrhages  and  infections.  The  hemor- 
rhages may  be  of  great  severity,  as  attacks  of  epistaxis ;  retinal  hemorrhages 
that  may  be  followed  by  more  or  less  permanent  blindness ;  and  hematurias  re- 
sembling those  of  renal  tuberculosis,  stone  or  tumor,  during  which  there  may 
be  alarming  losses  of  blood.  Hemorrhages  into  the  skin  and  the  mucous  mem- 
branes also  occur,  although  rarely,  during  this  stage.  Some  of  the  infections 
which  may  complicate  this  stage  are  erysipelas,  pneumonia,  anthrax  and  abscess 
formation. 

(3)  The  Ukemic  Stage. — During  the  uremic  stage,  in  addition  to  some  of 
the  symptoms  that  have  already  been  enumerated  under  the  minor  symptoms 
of  compensation  are  nausea,  vomiting,  diarrhea  and,  in  the  more  dangerous 
cases,  convulsions,  dry  tongue,  delirium,  stupor,  coma. 

Diagnosis. — The  diagnosis  of  chronic  interstitial  nephritis  is  usually  not 
difficult  when  the  disease  assumes  its  characteristic  clinical  type.  We  should 
pay  special  attention  to  the  presence  of  cardiac  hypertrophy,  as  shown  on  per- 
cussion by  the  increased  area  of  cardiac  dullness,  by  a  more  diffuse  pulsation 
and  by  the  apex  beat  being  found  in  the  sixth  intercostal  space,  one  to  three 
inches  to  the  left  of  the  nipple ;  to  increased  arterial  tension,  which,  instead  of 


428  NONSUPPURATIVE   NEPHRITIS 

beiiiii;  loU  to  140,  would  be  found  io  bo  140  to  180  or  liigbcr ;  to  arterial  .sclero- 
sis, which  would  show  as  thick  distended  tortuous  vessels  or,  later  on,  as  fibrous 
cords  that  roll  under  the  fini>ers ;  and  to  a  lariio  (|uautit_v  of  urine  with  a  low 
specific  gravity  and  the  presence  of  albumin  and  hyaline  casts. 

There  are  some  cases,  however,  in  which  the  diagnosis  is  more  difficult,  Ijc- 
cause  the  condition  is  marked  by  a  predominance  of  uremic  symptoms  resem- 
bling chronic  bronchitis,  gastro-intestinal  affections  and  cancer  of  the  stomach, 
owing  to  the  cachexia  present.  In  still  others,  the  marked  delirium  has  been 
looked  upon  as  a  sign  of  progressive  general  paralysis. 

Prognosis. — The  prognosis  of  this  form  of  no])hritis  is  always  gTave.  The 
disease  is  incurable,  but  the  patients  may  live  for  years  and  die  from  some 
other  disease.  The  only  consolation  is  that  the  course  is  usually  very  slow. 
The  prognosis  is  worse  when  the  symptoms  of  chronic  uremia  or  heart  failure 
are  present. 

TREATMENT   OF   NEPHRITIS 

Treatment  of  Acute  Nephritis. — The  first  steps  to  be  taken  are  to  have 
the  jDatient  kept  in  bed,  as  rest  is  most  important  both  for  the  heart  and  the 
kidneys,  after  which  an  attempt  should  be  made  to  eliminate  the  toxins  by 
giving  a  saline  purge,  such  as  sulphate  of  magnesia  an  ounce,  or  compound 
jalap  powder  half  a  drachm;  some  physicians  prefer  calomel  five  grains.  A 
diet  which  will  necessitate  as  little  work  on  the  part  of  the  kidney  as  possible 
should  then  be  given,  such  as  milk,  three  pints  a  day,  or  milk  with  one  third 
part  of  Yichy.  Wet  cups  should  be  applied  over  the  kidneys.  After  these  first 
steps,  the  patient  should  be  kept  on  a  milk  diet ;  the  bowels  should  be  kept  open 
by  mild  saline  laxatives,  such  as  citrate  of  magnesia,  Apenta  or  Carabafia 
water ;  and  hot-water  bags  should  be  kept  over  the  kidneys.  The  patient  should 
be  allowed  to  go  on  without  further  treatment,  unless  severe  symptoms  set  in, 
and  may  have  an  uneventful  recovery. 

In  more  severe  cases,  certain  symptoms  that  call  for  a  vigorous  treatment 
occur,  such  as  marked  edema  with  perhaps  an  involvement  of  the  serous  cavi- 
ties, or  those  of  uremia.  A  hydragogue  cathartic  should  then  be  given.  Ela- 
terium  is  the  most  efficient  of  all  hydragogue  cathartics  and  of  value  in  uremia, 
but  it  must  be  kept  in  mind  that  its  action  is  very  exhausting.  It  is  best  given 
in  combination  with  the  extract  of  belladonna  one  quarter  of  a  grain  each. 

If  this  is  not  sufficient  to  eliminate  the  toxins,  a  hot-air  bath  oi'  ])ack  should 
be  given  later.  When  this  fails  after  waiting  for  a  sufficient  interval,  pilocarjiin 
should  be  given.  This  is  most  useful  in  the  treatment  of  renal  dropsy  and  gen- 
erally exerts  a  marked  diaphoretic  action  when  given  internally  in  doses  of 
from  one  twelfth  to  one  sixth  of  a  grain. 

If  the  purge,  hot-air  bath  and  pilocarpin,  together  with  tlie  saline  diuretic, 
are  not  sufficient  to  benefit  the  Datient,  then  venesection  should  be  resorted  to. 


TEEATMENT    OF   NEPHRITIS  429 

followed  ])}■  nil  iiitrax'cnous  iiijrctiou  of  iiorinal  salt  solution.  In  ihis  ease,  400 
to  r>()0  e.c.  of  Mood  should  lie  withdrawn,  and  the  same  aiiioniit  of  salt  solution 
should  be  injected. 

When  the  flo^v  of  the  urine  is  scanty,  it  should  be  stimulated  by  liivinu-  as  a 
diuretic  citrate  of  i)otash,  ten  to  fifteen  grains  every  three  hours,  by  wdiicli  the 
severe  edema  and  uremia  just  mentioned  can  often  be  prevented. 

After  the  dangerous  symptoms  subside  by  this  means,  the  patient  should 
continue  with  the  milk  diet  and  with  saline  laxatives  if  constipation  is  pres- 
ent. The  saline  diuretics  should  be  given  again,  as  soon  as  the  urine  Ijegins 
to  become  scanty.  If  dangerous  symptoms  again  set  in,  the  same  vigorous 
measures  should  be  taken  to  combat  them  by  means  of  hydragogiie  cathartics, 
hot  packs,  pilocarpin  or  intravenous  saline  injections. 

Under  such  treatment,  most  patients  recover  in  from  six  to  eight  weeks; 
others  become  chronic ;  still  others  die,  especially  those  developing  anasarca  and 
uremia.  As  the  patient's  acute  symptoms  disappear  and  the  urine  increases  in 
quantity  and  elimination  is  better,  the  patient  can  be  gradually  changed  to  a 
more  varied  liquid  or  soft  diet,  as  broths,  cocoa,  bi?ead,  crackers,  rice  and  other 
carbohydrates,  and  sugar  and  butter  can  be  adclgd  if  the  digestion  permits. 
Some  also  allow  easily  digested  vegetables,  such  as  spinach,  cauliflower,  string 
beans  and  peas.  In  this  waj',  a  variety  is  furnished  and  the  patient  is  able  to 
maintain  a  partial  milk  diet  for  some  time.  As  a  beverage,  the  patient  may 
have  slightly  alkaline  table  waters,  or  lemonade,  or  water  slightly  tinged  with 
wine. 

Benzoate  of  soda  and  lactate  of  strontium  have  been  recommended  in  the 
treatment  of  acute  nephritis,  but  they  are  more  suitable  for  chronic  cases.  The 
benzoate  of  soda  acts  as  a  urinary  antiseptic  and  counteracts  the  causative  in- 
testinal fermentation  through  increasing  the  flow  of  bile.  The  lactate  of  stron- 
tium diminishes  the  amount  of  albumin  in  the  urine  but  does  not  increase 
the  flow. 

For  the  pain  in  the  loin,  dry  cups  or  hot  compresses  are  sufficient.  .  For  the 
hematuria,  ergot  or  tannic  acid  may  be  given  in  the  following  form  (Senator)  : 

Ergot grs.  V  (0.3  gram)  ; 

Tannic  acid    grs.  ss  (0.03  gram)  ; 

Powdered  gum  acacia grs.  viiss  (0.5  gram). 

To  be  taken  every  three  hours. 

The  constipation  which  these  drugs  produce  must  be  counteracted  by  ap- 
})ropriate  })urgatives,  such  as  Apenta  or  C^irabaua  water. 

Treatment  of  Chronic  Nephritis. — This  includes  preventive,  specific,  di- 
etetic, hygienic,  therapeutic  and  sym})tomatic  measures. 

Preventive. — The  probabilities  of  a  chronic  nephritis  following  an  acute 
attack  nuiy  be  very  much  lessened  by  very  carefully  managing  its  treatment  dur- 


430  NONSUPPURATIVE   NEPHRITIS 

ing  the  acute  stage  and  the  period  of  convalescence.  This  means  keeping  the 
patient  qniet  and  on  a  bland  diet  during  the  acute  stage  and  by  not  exposing 
him  to  bad  weather,  cold  or  draught  of  air  while  he  is  convalescing.  The  diet 
during  convalescence  should  be  very  simple  and  moderate,  free  from  condiments 
and  with  a  limited  amount  of  animal  proteids ;  or  it  may  be  salt  free  if  there 
is  a  tendency  to  edema,  or  such  a  condition  is  threatening. 

Specific  Treatment. — Most  cases  of  chronic  nephritis  are  incurable. 
Therefore,  the  aim  of  treatment  should  be  to  maintain  the  general  health  and 
assist  the  renal  functions  so  that  the  patient  can  continue  to  live  without  much 
inconvenience. 

Within  the  last  decade,  there  have  been  brought  forward  certain  special 
methods  of  treatment  which  are  intended  to  reach  the  disease  itself  and  to  im- 
jDrove  the  condition  more  or  less  permanently.  Organotherapy,  the  use  of 
renal  extracts,  is  not  yet  sufficiently  known  to  be  recommended.  My  own 
personal  experience  with  it  has  been  such  as  to  lead  me  to  prefer  the  older  reme- 
dies. The  second  form  of  treatment  under  this  category  is  the  surgical,  and 
that  of  the  iodids,  the  former  of  which  is  of  very  little  use,  except  in  the  case 
of  certain  complications. 

The  Iodids. — Sodium  and  potassium  iodids,  or  their  substitutes,  have  been 
used  in  chronic  nephritis,  especially  by  the  older  physicians.  I  frequently  use 
this  remedy  in  doses  of  two  or  three  grains,  three  times  a  day,  as  a  vaso-dilator 
in  arteriosclerotic  and  cardiac  changes.  It  is  also  supposed  to  modify  the  de- 
velopment of  the  lesions  in  the  kidney  and  to  prevent  the  formation  of  inter- 
stitial tissue.  Its  principal  value  is  in  cases  of  chronic  nephritis,  in  patients 
with  lead  poisoning  and  syphilis,  when  from  two  to  five  grains,  three  times  a 
day,  should  be  given. 

The  minor  symptoms  of  chronic  interstitial  nephritis,  due  to  arterial  hyper- 
tension and  appearing  in  the  shape  of  headache,  occasional  vertigo,  tinnitus  and 
epistaxis,  are  also  combated  with  potassium  iodid,  the  action  of  which  should  be 
carefully  watched.  Alternately  with  the  iodid  treatment,  glonoin  (solution  of  ni- 
troglycerin) is  recommended  by  Chauffard  and  may  be  given  in  doses  of  one  to 
two  drops.  Nitroglycerin  has  to  a  large  extent  taken  the  place  of  amyl  nitrite  in 
conditions  where  this  drug  is  indicated. 

SuKGiCAL  Treatment. — About  eight  years  ago,  my  colleague,  Dr.  Ede- 
bohls,  noticed  that  many  of  his  cases  of  movable  kidney  had  in  the  urine  before 
operation  a  slight  amount  of  albumin  and  a  few  hyaline  and  finely  granular 
casts  which  disappeared  after  partial  decapsulation  and  fixation  of  the  organ. 
He  accordingly  concluded,  first,  that  chronic  nephritis  could  be  unilateral  or 
bilateral,  and  second,  that,  if  the  partial  decapsulation  employed  in  nephropexy 
was  sufficient  to  cure  nephritis,  through  the  increased  blood  obtained  by  the 
anastomosis  between  the  partially  decapsulated  surface  of  the  organ  and  the 
adjoining  tissues,  then  a  more  extensive  decapsulation  would  give  a  greater 


i 


TEEATMENT    OF   NEPHEITIS  431 

exposed  surface  for  anastomosis  and  consequently  the  recovery  would  be  more 
certain.  He  accordingly  advocated  and  began  to  perform  an  operation,  called 
renal  decapsulation,  for  the  cure  of  chronic  nephritis,  which  consisted  in  en- 
tirely removing  the  capsula  propria  of  the  kidneys  and  replacing  them  in  their 
fatty  capsules.  He  claimed  that,  by  this  means,  an  anastomosis  of  good-siz.ed 
vessels  formed  between  the  kidney  and  the  fatty  capsule,  resulting  in  the  cure 
of  the  disease. 

I  performed  a  number  of  these  operations,  but  was  not  satisfied  with-  my 
results,  and  accordingly  wrote  to  many  of  the  leading  surgeons  of  the  country, 
asking  them  to  send  me  a  report  of  the  results  of  their  operations.  In  answer, 
I  received  reports  of  120  cases  that  had  recently  been  operated  upon,  16  per  cent 
of  which  were  reported  cured,  40  per  cent  improved,  11  per  cent  unimproved  and 
33  per  cent  of  deaths.  The  mortality  had  been  greatest  in  the  cases  diagnosti- 
cated as  diffuse  nephritis,  75  per  cent  of  which  had  died,  whereas  in  the  cases 
diagnosticated  as  parenchymatous  and  interstitial,  there  had  been  about  25  per 
cent  mortality  in  each  group. 

Some  time  after  this,  I  again  wrote  to  the  surgeons  who  had  contributed 
before  and  found  that,  among  those  of  their  patients  who  had  survived  the 
operation,  88,5  per  cent  had  since  died.  The  results  were  accordingly  not  such 
as  could  lead  me  to  advocate  renal  decapsulation. 

There  was,  however,  a  class  of  cases  that  had  been  very  much  benefited  by 
operation  and  this  comprised  cases  of  chronic  nephritis,  associated  with  hema- 
turia and  nephralgia.  These  cases  were  cured  of  the  attacks  of  hemorrhage  or 
pain  by  a  nephrotomy. 

The  conclusions  that  I  drew  from  the  studies  of  my  own  operations  and 
those  of  my  colleagues  were,  first,  that  total  decapsulation  of  the  kidney  is  an 
unwarranted  operation  which  should  never  be  performed ;  but  that  a  partial 
decapsulation  of  a  sufficient  area  of  the  surface  of  the  organ  to  assist  in  its  fixa- 
tion is  helpful  in  the  case  of  a  movable  kidney ;  second,  that,  in  cases  of  a  non- 
movable  kidney  in  which  there  is  much  tension  on  account  of  a  tight  capsule, 
this  will  be  removed  by  simply  incising  the  capsule  over  the  convexity ;  third, 
that,  if  there  are  symptoms  of  unilateral  nephralgia  or  hematuria,  a  nephrotomy 
is  satisfactory,  not  only  as  an  approved  operation,  but  also  as  an  exploratory 
means  of  determining  a  possibly  existing  surgical  disease. 

Geneeal  Treatment. — Rest  in  bed  is  important  whenever  an  acute  exacer- 
bation occurs,  associated  with  edemas,  scanty  or  bloody  urine,  or  uremic  symp- 
toms, during  which  time  the  patient  should  be  treated  as  a  case  of  acute  nephri- 
tis. If  it  is  found  that  rest  in  bed  does  not  improve  the  condition  of  the  urine, 
the  patient  may  be  allowed  to  get  up  and  lounge  about  the  h(~)use  in  reclining 
postures,  especially  if  the  disease  is  not  far  advanced.  If  the  heart  is  hyper- 
trophied  and  there  is  much  arterial  tension,  as  from  IGO  to  200  or  over,  and 
cardiac  symptoms,  such  as  palpitation  and  angina  pectoris,  headaches  or  diges- 


432 


NONSUPPURATIVE   NEPHRITIS 


tive  distin-Laiices  are  present,  rest  in  hcd  slioiild  be  maintained  until  llie  pa- 
tient im})r()ves.  Periods  of  rest  in  bed,  for  from  two  to  four  weeks  at  a 
time,  say  every  four  months,  are  of  considerable  benefit  in  many  ehronic 
cases  with  a  tendency  to  uremia.  The  patient's  general  condition  is  kept 
up  by  massage  while  undergoing  this  rest  treatment.  During  these  periods, 
the  diet  should  consist  of  milk  or  mixed  food,  whichever  agrees  better  with 
the  patient. 

Many  chronic  nephritics  go  on  for  years  attending  to  their  regular  pursuits 
of  life  without  taking  any  medical  treatment  for  the  disease.  Many  of  these 
patients  would  never  know  they  had  nephritis  unless  told  so  by  the  physician 
making  the  nrinary  analysis.  It  is  important  to  instruct  them  as  to  the  pro- 
tection of  back  and  chest  by 
suitable  clothing,  the  avoidance 
of  draughts,  or  any  prolonged 
exposure  to  cold  and  wet.  For 
the  protection  of  the  back  in 
male  patients,  I  recommend  a 
kidney  pad  or  protector  during 
the  cold  weather.  It  is  eas_y  to 
see  that  the  winter  vests  have 
thick  material  in  front  and  thin 
behind.  The  kidney  pad  is 
made  of  doubled  woolen  cloth 
sewed  together,  of  the  size  and 
shape  of  the  vest  back.  There 
are  nine  buttonholes  in  the  pad, 
and  nine  corresponding  buttons 
on  the  vest  to  which  they  are 
fitted.  The  same  pad  can  be 
used  with  a  number  of  vests. 
Besides  the  protection  it  affords 
the  lungs  and  back,  I  know  of  nothing  of  its  size  that  has  ever  given  me  so  nnich 
warmth  as  has  this  pad  (Fig.  278).  It  is  desirable  also  that  patients  should  pass 
a  number  of  hours  in  the  open  air  every  day,  if  possible,  provided  the  weather  is 
mild  and  pleasant. 

Climate. — A  change  of  climate  during  the  winter  to  a  warm,  dry,  evenly 
tempered  place  is  of  great  benefit.  Patients  are  sent  to  Egypt  or  Algiers,  or 
to  the  south  of  Italy  or  the  Riviera.  In  this  country,  Florida  and  Southern 
California  offer  excellent  climatic  conditions  for  nephritics. 

Diet. — The  diet  of  these  patients  should  be  moderate,  mixed  and  nonirri- 
tating.  They  should  learn  to  estimate  how  much  they  can  eat  without  doing 
themselves   harm,   or  else   should   regulate  the   diet   according   to   its   calories, 


Fig.  278. — Kidney  Pad  to  Be  Buttoned  on  the  Back 
OF  A  Vest  as  a  Protection  for  Nephretics. 


TREATMENT    OF   NEPHRITIS  433 

and  tliey  should  know  that  their  longevity  depends  on  eating  certain  foods  and 
in  sncli  amounts  as  they  can  easily  digest,  assimilate  and  eliminate. 

Milk  is  the  ideal  food  for  the  patient  with  Bright's  disease,  because  it  is 
highly  nutritious,  contains  but  few  toxic  substances  and  promotes  the  excre- 
tion of  urine.  Yet  an  absolute  milk  diet  is  not  necessary  except  in  acute  exacer- 
bations, or  in  eases  in  which  the  major  symptoms  of  uremia  threaten  to  develop. 

Again,  a  diet  of  milk  alone  is  not  sufficient  in  chronic  nephritis  during  the 
stage  of  compensation,  and,  when  prolonged,  it  leads  to  gastric  intolerance  and 
to  a  general  debility  with  sluggishness  in  the  functions  of  various  organs.  Be- 
sides, if  milk  diet  be  instituted  too  early,  it  will  be  difficult  to  keep  it  up  later 
on  in  the  disease  when  it  is  indispensable. 

When  an  absolute  milk  diet  is  necessary,  it  should  be  given  in  small  quan- 
tities at  frequent  intervals.  The  amount  needed  for  the  maintenance  of  the 
body  weight  is  about  three  liters  in  twenty-four  hours,  but  this  is  entirely  too 
much  fluid  and  two  liters  usually  mark  the  degree  of  tolerance,  while  one  liter 
daily  is  sufficient  for  a  short  interval  or  for  a  longer  period,  if  combined  with 
other  food.  Milk  can  be  taken  hot  or  cold  or  flavored  wath  a  little  sugar  or  a 
small  quantity  of  cocoa.  It  is  more  easily  digested  when  mixed  with  Vichy 
or  some  similar  alkaline  mineral  water.  If  not  well  borne,  it  can  be  given  pre- 
digested  by  means  of  pancreatin.  Substitutes  for  milk,  such  as  koumiss,  may 
also  be  used. 

Milk  diet  often  causes  constipation,  thus  necessitating  the  daily  use  of  laxa- 
tives or  cold-water  enemas.  Sometimes  fecal  impactions  form,  so  that  enemas 
of  oil  or  even  mechanical  removal  of  the  masses  is  necessary.  In  other  patients, 
a  milk  diet  causes  diarrhea  for  which  bismuth  should  be  used  internally. 

A  diet  free  from  chlorids  has  of  late  years  taken  the  place,  in  a  measure,  of 
the  absolute  milk  diet.  This  method  of  treatment  is  indicated  in  cases  of  chronic 
parenchymatous  nephritis  with  dropsy  and  has  already  been  spoken  of.  The 
dropsy  can  sometimes  be  made  to  disappear  in  patients  by  giving  them  a  diet 
free  from  chlorids,  but  will  reappear  again  on  adding  sodium  chlorid  to  the 
food.  An  absolute  salt-free  diet  should  not  be  continued  for  any  length  of  time, 
as  the  system  requires  six  grams  of  salt  a  day.  This  represents  the  amount  of 
salt  in  three  quarts  of  milk.  The  amount  of  salt  to  the  liter  is  approximately 
two  grams. 

The  advantage  of  the  chlorid-free  diet  is  that  it  offers  a  choice  between  a 
number  of  articles  of  food.  Meat  contains  very  little  chlorids,  which  are  lost 
completely  when  it  is  boiled.  Eggs,  vegetables,  potatoes,  lentils,  rice  and 
farinaceous  food  contain  but  small  amounts  of  chlorids.  Among  the  fresh  vege- 
tables, green  peas,  carrots,  turnips  and  string  beans  may  be  chosen  as  contain- 
ing little  salt.  In  some  cases,  after  a  period  of  such  a  diet,  the  patient  can 
return  to  ordinary  food  and  can  tolerate  more  salt.  In  other  cases,  as  soon  as 
salt  is  given,  the  symptoms  reappear. 


434  NONSUPPURATIVE   NEPHRITIS 

There  is  a  class  of  cases,  also,  in  whicli  the  salt-free  diet  does  not  lessen 
the  edema  nor  prevent  uremia.  It  is  probable  that  in  these  cases  the  exclusion 
of  chlorids  from  the  food  is  not  enough  to  relieve  the  system  of  an  excess  of 
chlorids.  There  are  also  some  patients  in  whom  a  chlorid-free  diet  causes  an 
increased  albuminuria.  All  patients  should  be  carefully  watched  while  on  this 
diet.  If  the  edemas  have  disappeared,  the  salt  may  be  g-radually  increased  while 
the  return  of  symptoms  are  watched  for.  If  they  return,  the  amo\int  of  salt 
should  be  reduced  again. 

Quantity  of  Fluid. — An  important  rule  in  chronic  nephritis  is  never  to  ex- 
ceed a  definite  quantity  of  fluid  ingested  in  twenty-four  hours  and  in  this  way 
to  avoid  overloading  the  heart.  The  heart  in  these  cases  is  already  overworked 
and  must  not  be  strained  too  much.  The  average  daily  quantity  of  fluid  should 
not  exceed  one  and  a  half  liters.  It  is  for  this  reason  that  an  absolute  milk  diet 
is  difficult  to  maintain  without  impairing  the  nutrition  of  the  patient.  If  we 
wish  to  give  the  patient  the  full  amount  of  nutriment,  we  ought  to  give  from 
three  to  four  liters  of  milk  a  day ;  this  is  obviously  unwise,  as  we  would  thus 
exceed  the  limit  of  fluid  capacity  of  the  organism. 

Van  ISTorden  recommends  a  liter  and  a  quarter  of  fluid  a  day  and  says  that  a 
person  taking  this  amount  should  pass  from  one  and  one  third  to  one  and  one 
half  liters  of  urine  daily. 

The  liquids  besides  water  allowed  in  chronic  nephritis  are  milk,  lemonades 
or  sour  drinks  and  the  alkaline  mineral  waters,  especially  Celestine  Vichy. 
Mineral-water  cures,  as  such,  cannot  be  expected  to  cure  the  disease,  but  are 
sometimes  beneficial  to  the  extent  to  which  they  improve  the  patient's  general 
condition.  Carlsbad,  Vichy  and  ISTeuenahr  are  advised  when  there  is  not  much 
hypertroj)hy  of  the  heart,  and  but  slight  increase  of  arterial  tension  and  no 
dropsy.  On  the  other  hand,  when  there  is  a  tense  pulse  and  a  markedly  hyper- 
trophied  heart,  such  springs  must  be  avoided  and  Marienbad  or  Kissingen  may 
be  recommendedo  Carhonic-acid  baths  may  be  used  at  home  when  the  patient 
is  no  longer  able  to  stand  the  journey  to  the  watering  places,  and  are  beneficial 
in  high  arterial  tension.  They  are  made  by  charging  the  water  in  a  bath  from 
a  tank  of  carbonic-acid  gas.  The  duration  of  the  bath  should  be  from  eight  to 
twenty  minutes,  after  which  the  patient  should  rest  for  an  hour.  By  this  means, 
the  pulse  is  slowed  and  the  pressure  considerably  diminished. 

Alcohol  should  not  be  allowed,  or  else  should  be  given  only  in  very  small 
quantities  in  the  form  of  light  wines,  such  as  a  glass  of  Bordeaux,  or  Zinfandelj 
from  California,  alone  or  mixed  with  plain  water  or  mineral  waters.  Beer] 
and  champagne  and  the  stronger  wines  are  very  injurious,  as  they  either  irri- 
tate or  cause  fermentation,  thus  interfering  with  digestion.  Whisky  with 
water,  well  diluted,  is  allowed  by  some  on  the  plea  of  improvement  of  the  pa- 
tient's nutrition.  Alcoholics  are  less  harmful  in  chronic  parenchymatous  than 
in  the  interstitial  form  of  nephritis. 


TREATMENT    OF    NEPHRITIS  435 

Coffee,  tea  and  tobacco  are  cardinr  stiimilants  and  for  this  reason  should  not 
be  allowed,  as  they  tend  to  overwoik  the  heart  and  wear  it  out.  Walking 
}5atients  with  a  mild  degree  of  nephritis  do  fre(iuently  indulge  in  all  these 
stimulants,  but  those  with  cardiac  and  vascular  changes  should  be  more 
cautious. 

Meat  can  be  allowed  to  nephritics  in  a  certain  amount  once  a  day.  White 
meats  are  usually  recommended,  as  they  contain  slightly  less  extractives  and 
proteins.  Yeal,  pork,  lamb  and  poultry  are  considered  the  best,  although  opin- 
ions regarding  them  vary.  I  do  not  attach  much  importance  to  the  color  of 
the  meat,  and  allow  beef  and  mutton  with  the  same  frequency  as  the  white 
meats.  Meat  should  be  taken  at  the  midday  meal,  which  should  be  the  principal 
meal  of  the  day.     They  are  best  prepared  boiled,  broiled  or  roasted. 

Fish  can  be  taken  prepared  in  the  same  way.  Fish  is  not  as  difficult  to 
digest  as  meat.  It  is  classed  by  some  among  the  white  meats.  Once  a  day  is 
also  sufficient  for  fish  and  it  should  not  be  taken  at  the  same  meal  as  the  meat, 
except  in  half  quantities  of  each. 

Eggs  are  considered  as  undesirable  food  by  some  and  approved  by  others.  In 
many  patients,  an  egg  will  increase  the  amount  of  albumin  in  the  urine,  whereas 
in  other  cases  it  has  no  effect  upon  it.  Eggs  should  be  boiled,  poached  or 
shirred.  One  egg  a  day  is  sufficient  for  a  nephritic  and  is  best  taken  in  the 
morning. 

Vegetables  are  quite  freely  allowed  in  chronic  nephritis,  although  physi- 
cians differ  in  their  choice.  The  allowed  list  contains  rice,  lentils,  peas,  green 
beans,  asparagus,  tomatoes,  potatoes,  carrots  and  turnips.  Personally,  I  do 
not  allow  asparagus  and  tomatoes,  which  are  on  the  list  because  they  do  not 
contain  much  protein  matter.     I  prefer  rice,  green  peas  and  green  beans. 

Farinaceous  foods  are  also  allowed,  as  bread,  properly  toasted,  and  the 
cereals,  hominy,  farina  and  wheatena.  Fats,  carbohydrates  and  fruits  are  con- 
sidered by  many  as  valuable  tissue  builders  in  these  cases,  and  can  be  taken  in 
moderation  if  they  are  well  tolerated.  Grapes  and  apples  are  probably  the  best 
fruits  for  nephritics. 

From  this  list  it  will  be  seen  that  the  variety  is  sufficient  but  that  care  must 
be  taken  not  to  eat  too  much,  for  overeating  is  one  of  the  causes  of  chronic 
nephritis  as  well  as  being  one  of  the  chief  factors  in  hurrying  the  death  of  the 
patient  who  is  suffering  from  this  trouble.  Condiments,  as  all  pickled  and 
smoked  foods,  spices,  pepper,  paprika,  catsups,  mustard,  radishes,  horseradish 
and  garlic  should  be  interdicted. 

Hygiene  and  Mode  of  Life. — Persons  with  chronic  nephritis  must  live 
strictly  according  to  the  ndes  of  hygiene.  Excessive  exercise  and  exertion 
should  be  avoided,  as  giving  rise  to  an  overproduction  of  waste  to  be  excreted 
by  the  kidney.  Pest  is  essential  during  acute  exacerbations  and  in  the  presence 
of  impending  uremia.     Chronic  nephritics  are  not  fit  for  excessive  mental  work, 


436  NONSUPPURATIVE   NEPHRITIS 

as  this  is  apt  to  produce  indigestion,  which  indirectly  means  extra  work  for  the 
kidney. 

The  function  of  the  bowels  and  the  skin  should  he  regulated  and  the  patient 
should  avoid  extremes  of  cold  and  wet. 

Symptomatic  Tkeatment. — This  is  addressed  to  the  symptoms  as  they 
arise  in  the  different  types  of  chronic  nephritis. 

In  early  cases  of  chronic  parenchymatous  nephritis,  before  cardiac  valvular 
changes  have  had  time  to  develop,  the  arterial  tension  is  sometimes  so  low,  that 
digitalis,  caffein  and  spartein  are  often  used  on  account  of  their  effect  in 
strengthening  and  regulating  the  heart  action. 

Beginning  Edemas. — When  a  patient  with  chronic  parenchymatous  nephri- 
tis complains  of  lumbar  pain,  wdiile  his  eyelids  appear  puffed  up  and  edematous, 
his  urine  should  be  examined  and,  if  evidences  of  an  acute  exacerbation  are 
present,  he  should  be  put  to  bed  and  treated  the  same  as  for  an  attack  of  acute 
nephritis. 

General  edema  is  threatened  when  the  urine  becomes  scanty  and  of  a  high 
specific  gravity,  containing  a  considerable  amount  of  albumin  and  casts.  A 
purge  of  jalap  powder  or  elaterium  should  be  given  and  diuretic  remedies  are 
indicated,  selecting  those  which  act  upon  the  glomeruli  and  promote  excretion 
without  irritating  the  tubules,  such  as  the  theobromin  preparations.  In  such 
cases,  the  following  diuretics  should  be  given  until  the  symptoms  have  been 
relieved,  when  they  should  be  discontinued.  Diuretin  (salicylate  of  sodium 
theobromin)  does  not  irritate  the  kidney,  rarely  causes  disagTceable  symptoms 
and  is  a  diuretic  that  I  consider  most  reliable.  In  the  course  of  the  day,  from 
60  to  120  grains  (4  to  8  grams)  may  be  given  in  divided  doses  in  capsules  or 
solution  or  hypodermically.  Theocin,  a  synthetic  alkaloid  of  theobromin,  has  also 
been  found  to  act  as  a  very  reliable  diuretic,  more  so  than  theobromin  itself  or 
caffein,  increasing  both  the  excretion  of  water  and  solids  from  the  kidney,  and 
useful  for  the  control  of  dropsy.  It  is  prescribed  in  small  doses,  frequently 
repeated,  so  as  to  avoid  gastric  irritation.  Up  to  8  grains  daily  may  be  given 
(0.5  to  0.75  gTam)  the  effect  being  usually  most  evident  on  the  second  or  third 
day  after  the  administration  of  the  drug.  Diuresis  cannot,  however,  be  main- 
tained by  means  of  this  drug,  as  the  system  soon  becomes  accustomed  to  its  use. 
Agurin,  a  preparation  consisting  of  theobromin-sodium  and  sodium  acetate,  is 
prescribed  in  cases  of  renal  dropsy  in  the  form  of  a  powder,  to  be  taken  in  dilute 
solution  or  in  capsules,  in  doses  of  from  5  to  15  gi-ains  three  to  six  times  daily. 
Another  very  useful  remedy  in  oliguria  (scanty  urine)  is  potassium  acetate,  in 
5  to  15  grain  doses,  every  three  hours. 

Apocynum,  Canadian  hemp,  assists  the  elimination  of  fluid  that  has  accumu- 
lated in  chronic  Bright's  disease  and  may  be  given  in  doses  of  5  to  15  minims 
(0.3  to  1.0  c.c.)  of  the  fluid  extract. 

If  the  threatening  edema  is  not  relieved  by  diuretics  and  other  methods  of 


AMYLOID   KIDNEY 


437 


treatment  already  outlined  and  the  edema  extends  to  the  lower  extremities  and 
serous  cavities,  as  it  frequently  does  in  the  later  stages  of  parenchymatous 
nephritis,  internal  medication  should  be  assisted  by  physical  measures,  such  as 
hot  baths,  followed  by  packs  to  promote  sweating  and  thereby  favor  the  elimina- 
tion of  toxins.  It  is  a  noteworthy  fact,  however,  pointed  out  by  Landouzy,  that 
100  liters  of  sweat  would  be  required  as  an  equivalent  of  1,500  gTams  of  urine. 
Hence,  the  kidney  must  always  be  relied  upon  as  the  safest  cliannel  of  drain- 
age for  the  impurities  of  the  organism. 

In  the  general  dropsy  of  chronic  nephritis,  aspiration  of  the  body  cavities 
affords  not  only  a  local  relief,  but  the  general  condition  improves,  the  uremic 
sym])toms  are  lessened  and  tlie  diuresis  is  increased.  This  is  probably  due  to 
uremic  poisons  in  the  blood  leaving  the  body  with  the  trans- 
udating  fluid. 

The  use  of  Southey's  tubes  (Fig.  279)  have  been  recom- 
mended for  the  drainaji'e  of  edematous  areas,  including  the 
extremities,  to  relieve  the  tension  of  the  overdistended  tis- 
sues. They  are  made  of  metal  from  3  to  9  cm.  long  with  a 
lumen  of  1 5^  to  3  mm.,  resembling  trocars,  but  perforated  on 
the  sides.  Two  or  more  of  these  tnbes  are  pushed  into  the 
subcutaneous  tissue,  the  stilet  withdrawn  and  a  rubber  tube 
attached,  leading  into  a  receptacle  for  drainage.  They  are 
left  in  from  twelve  to  twenty-four  hours.  The  puncture 
continues  to  leak  for  some  time  after  the  removal  of 
the  tubes.  In  this  way,  two  quarts  of  fluid  a  day  will 
sometimes  escape.  During  the  time  that  operations  by 
renal  decapsulation  were  being  performed  for  the  treat- 
ment of  chronic  nephritis,  the  incision  in  the  loin,  made 
in  patients  suffering  from  chronic  parenchymatous  ne- 
phritis, sometimes  did  not  close,  but  acted  as  a  drain 
and  large  quantities  of  edematous  fluid  leaked  through  the  loin  continu- 
ously. Some  of  the  patients  operated,  who  were  apparently  very  stout, 
having  thick  abdominal  walls,  rapidly  appeared  emaciated  after  the  opera- 
tion. 


Fig.  279. — Southey's 
Tubes.  (To  be 
obtained  from  Tie- 
man.) 


AMYLOID   KIDNEY 

Amyloid  kidney  is  a  condition  of  amyloid  degeneration  in  that  organ,  which 
usually  accompanies  amyloid  changes  in  other  viscera,  such  as  the  spleen  and 
the  liver.  Amyloid  kidney  was  first  described  by  Eokitansky,  in  1842,  but  the 
term  was  introduced  l)v  Virchow,  in  1855. 

Etiology. — Amyloid  degeneration  of  the  kidneys  is  due  to  any  chronic  in- 
fectious disease  which  gives  rise  to  a  cachexia.  Of  these,  the  principal  ones 
are   tuberculosis,    chronic    suj)puration    and    syphilis,    but    the    condition    has 


438  NOXSUPPUKATIVE    NEPHRITIS 

also  been  observed  in  chronic  malaria,  in  leprosy  and  in  arthritis  deformans. 
Experimentally,  amyloid  degeneration  has  been  produced  by  the  injection  of 
the  bacilli  or  the  toxins  of  bacillus  pyocyaneus. 

Patholog-y. — At  autopsy,  the  amyloid  kidney  resembles  very  closely  the 
large  white  kidneys  of  chronic  nephritis  with  dropsy  (chronic  parenchymatous 
nephritis),  so  that  the  conditions  are  often  mistaken  for  each  other.  If  the 
surface  of  the  cut  kidney  is  treated  with  tincture  of  iodin,  the  degenerated  por- 
tions will  turn  a  mahogany  brown,  while  the  unaffected  portions  will  remain 
yellow.     If  sulphuric  acid  is  then  applied,  the  degenerated  zones  turn  blue. 

On  gross  examination,  the  amyloid  kidney  is  large,  pale,  firm  and  non- 
elastic,  waxy  in  consistence.  Its  capsule  is  smooth  and  easily  detached.  On 
section,  the  tissue  is  colorless,  often  glistening,  the  cortex  swollen  and  yellowish 
white,  the  medullary  portion  dark. 

On  microscopical  examination,  amyloid  tissue  assumes  peculiar  coloring 
with  anilin  dyes.  Thus,  with  methyl  or  gentian  violet,  the  amyloid  tissue 
stains  pink;  with  methyl  gTeen,  the  kidney  stains  a  green  color  except  the 
amyloid  portions,  which  stain  violet.  The  organ  should  not  be  fixed  in  alcohol 
previous  to  staining,  inasmuch  as  alcohol  dissolves  the  amyloid  substance. 

The  lesions  under  the  microscope  are  usually  well  scattered  through  the 
kidney,  including  the  blood  vessels,  the  connective  tissue  and  the  epitlielia.  The 
blood  vessels  are  the  most  frequent  seat  of  degeneration,  the  glomerular  capil- 
laries showing  amyloid  degeneration  early  in  the  disease ;  next,  the  capil- 
laries of  the  cortex  and  last  the  straight  vessels  of  the  medulla.  All  these 
arterial  channels  become  gradually  obliterated  by  the  amyloid  changes.  Occa- 
sionally, the  interstitial  tissue  is  also  affected  by  the  amyloid  changes.  The 
tubular  epithelia  themselves,  however,  are  usually  free  from  these  changes, 
although  they  may  be  the  seat  of  fatty  degeneration. 

As  the  result  of  the  amyloid  changes  in  the  arteries  and  coimective  tissue, 
the  tubular  structures  gradually  undergo  the  same  changes  as  are  seen  in  chronic 
nephritis. 

Symptoms. — There  are  always  the  symptoms  of  amyloid  degeneration  of 
other  organs.  The  kidney  is  but  slowly  affected  and  the  disease  develops  in- 
sidiously. 

The  chief  phenomena  are  in  the  urine.  A  frequent  Ijut  inconstant  symp- 
tom is  the  polyuria,  w^hich  may  amount  to  from  2  to  6  liters  in  twenty-four 
hours.  The  urine  is  clear,  light  colored,  wuth  low  specific  gravity,  and  con- 
tains nothing  of  importance  in  the  sediment.  When  there  are  abundant  diar- 
rheas, the  polyuria  may  be  absent  and  the  -same  is  true  sometimes  in  the  last 
stages  of  the  disease,  when  there  is  heart  failure. 

The  amount  of  albumin  is  usually  considerable,  increasing  gi-adually  until 
it  reaches  20  or  30  grams  daily.  According  to  Senator,  this  albuminuria  con- 
sists in  great  part  of  globulin.     The  urea,  chlorids,  phosphates,  etc.,  are  some- 


AMYLOID   KIDNEY  439 

^vliat  diininislied  in  ainoimt.  Ilyuliuc  and  granular  casts  are  sometimes  found 
in  the  sediment,  owing  to  the  presence  of  a  nephritis.  But  there  are  never 
casts  having  an  amyloid  reaction. 

Amyloid  kidney  does  not  give  rise  to  edemas  or  to  uremic  symptoms.  When 
these  are  present,  they  are  due  to  the  accompanying  nei:»hritis. 

Diagnosis. — The  diagnosis  is  made  by  the  presence  of  a  polyuria,  with  a 
large  amount  of  albumin  in  cachectic  patients  suffering  from  tuberculosis 
or  syphilis  or  some  chronic  snppurative  condition,  particularly  if  there 
is  a  hypertrophy  of  the  liver  and  the  spleen  to  strengthen  the  diagnosis. 
The  diagnosis  from  interstitial  nephritis  is  made  bj'  the  absence  of  uremic 
symptoms,  of  high  arterial  tension  and  of  cardiac  hypertrophy,  also  because 
the  urine  is  paler  and  there  is  a  smaller  amount  of  albumin  in  interstitial 
nephritis. 

Treatment. — The  treatment  of  amyloid  nephritis  consists  in  the  main- 
tenance of  a  mixed  diet  of  milk  and  vegetables,  the  administration  of  iodids  in 
syphilitics  and  the  general  care  of  the  primary  condition  in  tuberculosis,  etc. 
When  a  complicating  nephritis  exists,  it  should  be  treated  according  to  the 
manner  indicated  in  the  chapter  on  Chronic  ISTephritis. 


CHAPTER    XXIV 

UREMIA 

Uremia  (  ovpov,  urine,  atfta,  l)]oofl)  is  a  toxic  condition  due  to  the  accumu- 
lation or  retention  in  the  hlood  of  urine,  urinary  constituents  or  excreuientitious 
substances  usually  throAvn  off  by  the  kidneys.  It  gives  rise  to  a  more  or  less 
complex  group  of  symptoms,  such  as  headache,  nausea,  vomiting,  convulsions, 
coma,  visual  disturbance,  a  urinary  odor  to  the  breath  and  sometimes  hemiplegia. 

Etiology. — A  variety  of  theories  as  to  the  cause  of  uremia,  each  based  on 
more  or  less  experimental  evidence,  will  here  be  mentioned  for  their  historical 
interest.  The  condition  that  is  spoken  of  as  uremia  was  first  made  known 
through  the  work  of  Bright  on  nephritis,  but  the  term  itself  was  first  used  by 
Piorry,  after  Wilson  had  brought  forward  the  theory  that  the  symptoms  were 
due  to  a  retention  of  urea  in  the  blood  (1833). 

The  j^riucipal  theories  of  uremia  may  be  tabulated  as  follows : 

(1)  MECHANICAL  (Traubc,  1861). — Uremia  is  due  to  cerebral  edema. 

(2)  toxic:  monotoxic  theories. 

(a)  Due  to  the  retention  of  urea  in  the  blood.     (Wilson,  1833. ) 

(b)  Due  to  the  formation  of  ammonium  carbonate  in  the  blood  by  micro- 
coccus urea.      (Frerichs,  1851.) 

(c)  Due  to  fermentation  of  ammonium  carbonate  in  the  stomach  and  intes- 
tines from  urea,  and  the  absorption  of  the  former  into  the  blood.  (Treitz; 
confirmed  by  Landois  and  Pavloff.) 

(d)  Due  to  the  accumulation  of  kreatin,  kreatinin,  uric  acid,  etc.,  as  result 
of  changes  in  metabolism,      (Schottin;  Voit ;  Chalvet.) 

(e)  Due  to  intoxication  by  the  retention  of  urinary  coloring  matters. 
(Thudicum,) 

(/)  Due  to  intoxication  with  iwtassium  salts,  (Feltz  and  Rittcr.  Injec- 
tion of  K.  salts  in  proportion  occurring  in  urine  was  fatal  in  animals. ) 

(g)  Due  to  retention  of  chlorids  causing  edema  of  the  brain,  etc.  (Widal 
and  Javal.) 

(3)  toxic:  polytoxtc  theory,     (Bouchard,) 

ISTot  a  single  toxic  substance,  but  a  number  of  various  poisons  retained  in  the 
blood  cause  uremia. 

Practically  all  the  research  work  done  in  uremia  since  1881  is  based  upon 
440 


ETIOLOGY  441 

the  theory  of  Bouchard.  Ilis  dcfiiiition  of  the  syinptoin  complex  is  that  uremia 
is  ail  intoxication  by  poisons,  either  introduced  from  without  or  formed  in  the 
body,  which  are  n(.)rmally  elimiiuited  by  the  kidneys  in  the  urine,  but  in  c(;rtain 
conditions  are  retained,  owing  to  renal  impermeability.  According  to  this  in- 
vestigator, forty-seven  per  cent  of  the  poisonous  effects  of  the  urinary  cou- 
stituents  are  due  to  potassium  salts ;  urea,  ammonium  carbonate,  the  extractives, 
the  coloring  matters,  etc.,  may  each  play  their  part  in  the  intoxication.  Five 
distinct  poisons,  the  chemical  nature  of  Avhich  is  not  known,  were  isolated  by 
Bouchard  from  the  urine. 

A  series  of  experimental  studies  on  the  permeability  of  the  kidney  have  been 
published  since,  especially  in  France,  and  some  recent  investigators  doubt  the 
importance  of  renal  impermeability  in  the  production  of  uremia  (Bernard). 
Insufficiency  of  the  internal  secretion  of  the  kidneys  and  the  liver,  with  failing 
compensatit>n  of  the  heart  and  increasing  arterial  tension,  are  believed  l)v  them 
to  be  sufficient  etiological  factors,  without  any  renal  impermeal)ility.  The 
significance  of  toxic  retention  and  renal  impermeability  is  held  by  other 
observers,  who  explain  the  occasional  absence  of  toxic  substances  from  the 
blood  in  uremia  by  their  absorption  on  the  part  of  the  tissues.  (Castaigne, 
Achard.) 

The  retention  of  chlorids  in  the  body  has  also  been  pointed  out  as  a  factor 

in   the  mechanism   of   uremia.      (Widal   and    Javal,    Bohne. )      According   to 

^  Castaigne,  uremia  is  due  to  the  retention  in  the  body  of  multiple  toxins  from 

various  sources  and  the  retention  of  chlorids,  both  being  the  result  of  renal 

impermeability,  without  which  no  uremic  poisoning  can  take  place. 

The  occurrence  of  uremia  is  dependent  upon  (1)  the  presence  of  a  renal 
disease,  either  acute  or  chronic  nephritis,  pyelo-nephritis  or  pyonephrosis,  cystic 
kidney  or  renal  abscess;  (2)  upon  the  presence  of  renal  obstruction,  such  as 
calculus  in  the  ureter,  ureteral  stricture  or  pressure  upon  the  duct,  in  the  blad- 
der or  somewhere  along  its  course. 

Patients  suffering  from  an  acute  affection  of  the  kidney  producing  anuria, 
such  as  acute  nephritis  or  an  acute  exacerbation  of  chronic  nephritis,  are  liable 
to  an  acute  attack  of  uremia.  In  the  absence  of  predisposing  factors,  patients 
with  chronic  disease  of  the  kidney  may  remain  free  from  uremic  manifesta- 
tions for  years.  The  causes  that  favor  or  immediately  induce  the  appearance 
of  the  uremic  symptom  complex  may  be  summed  up  as  follows : 

(1)  Increase  in  the  work  of  the  kidneys,  due  to  overeating  or  drinking. 

(2)  Intercurrent  acute  nephritis,  exposure  to  cold,  wet,  fatigue,  any  cause 
producing  congestion  of  the  kidneys. 

(3)  Complicating  extrarenal  intoxications:  Influenza  (in  old  age)  and 
other  acute  infectious  diseases  occurring  in  chronic  nephritis. 

(4)  Arrest  or  diminution  of  toxin  elimination,  by  treatment  or  conditions 
which  arrest  sweating,  defecation,  vomiting  and  urination. 


442  UEEMIA 

Symptoms. — Tlio  symptoms  of  uremia  vary  according  to  the  character, 
strength  and  degree  of  the  intoxication,  as  well  as  the  predisposition  and  re- 
sistance of  certain  organs  or  groups  of  organs.  Clinically,  there  are  two  vari- 
eties of  acute  and  chronic  uremia.  Acute  uremia  may  occur  in  acute  ne])hritis, 
or  in  the  course  of  chronic  lesions  of  the  kidney,  and  may  be  the  first  indication 
of  the  presence  of  renal  disease. 

Acute  Uremia. — The  hyj)eracute  form  is  characterized  by  a  sudden  attack, 
without  premonitory  symptoms,  of  faintness,  vertigo  and  coma,  which  is  fol- 
lowed by  death  within  a  short  time.  As  a  rule,  such  patients  for  months  or 
years  have  been  sufPering  from  chronic  uremia,  but  the  true  nature  of  their  ill- 
ness has  remained  unrecognized  to  the  end. 

The  acute  form  also  comes  on  suddeidy,  but  is  preceded  by  premonitory 
symptoms,  such  as  headache,  vomiting,  oliguria  or  anuria,  or  disturbances  of 
vision  and  hearing  (contraction  of  the  pupil,  double  vision,  partial  or  total 
blindness,  noises  in  the  ears,  sudden  deafness).  There  may  have  been  also  slight 
delirium  and  a  tendency  to  aphasia. 

The  acute  attack  is  characterized  by  convulsions,  delirium,  somnolence  and 
coma.  There  may  also  be  intense  dyspnea,  asthmatic  breathing  or  Cheyne- 
Stokes  respiration,  or  the  dominant  symptom  may  be  vomiting  and  diarrhea. 
Paralyses  have  been  reported  in  this  connection,  especially  by  French 
writers. 

Latent  ok  Mild  Ukemia  (Lecorche  and  Talamon's  Attenuated  Uremia). — 
There  are  cases  of  chronic  disease  of  the  kidneys  in  which  the  uremia  is  so  mild 
and  is  accompanied  by  so  few  typical  symi^toms,  that  it  is  apt  to  be  mistaken 
.  for  some  less  serious  trouble.  Only  when  the  urine  is  repeatedly  examined  and 
the  case  studied  thoroughly,  may  we  make  out  the  uremic  origin  of  the  mild 
symptoms  complained  of  by  the  patient. 

This  mild  form  of  chronic  uremia  may  persist  for  a  long  time  without  be- 
coming aggTavated,  or  it  may  be  the  precursor  of  the  more  severe  type  known 
to  the  French  writers  as  "  grande  uremie." 

Headache  is  the  leading  symptom  in  many  such  cases  of  mild  uremia.  It 
may  for  a  long  time  be  the  only  symptom  present,  and  may  vary  greatly  in 
intensity.  IvText  to  headache,  there  are  a  variety  of  muscular  and  neuralgic  pains 
which  frequently  accompany  mild  uremias.  Uremic  intoxication  may  give  rise 
to  a  neuritis  like  that  of  alcohol  and  lead,  and  one  form  of  such  a  neuritis  is 
that  of  the  cardiac  plexus  known  as  angina  pectoris.  Facial  and  other  neural- 
gias may  also  occur  in  mild  uremia. 

A  variety  of  aches  in  the  muscles  and  the  joints,  and  cramplike  contrac- 
tions of  the  sole  of  the  foot,  are  also  complained  of.  The  patients  behave  like 
rheumatics  and  are  frequently  given  salicylates  erroneously.  I^umbness,  prick- 
ing sensations  in  various  parts  of  the  body,  including  the  common  phenomenon 
of  "  dead  finger,"  may  also  occur.     (Dieulafoy.) 


i 


SYMPTOMS  443 

Finally,  the  mild  form  may  be  accompanied  by  disturbances  of  vision  and 
hearing,  of  which  we  shall  speak  further  on,  and  occasionally  there  are  attacks 
of  asthma  without  any  organic  cause,  due  to  toxic  influence. 

CiiKONic  Ukemja. — In  the  chronic  form,  the  symptoms  are  usually  rather 
indefinite.  Headaches,  neuralgias,  respiratory  disturbances,  attacks  of  asthma 
or  disturbances  of  vision  or  hearing,  come  on  at  irregular  intervals,  provoked 
usually  by  exposure  to  cold,  fatigue,  or  excesses  in  eating  or  drinking.  Gradu- 
ally these  attacks  become  more  frequent,  and  the  final  stage  is  heralded  by  a 
period  during  which  vomiting,  diarrhea  and  loss  of  appetHe  are  prominent. 
The  patient  loses  weight,  becomes  weak  and  anemic,  and  gradually  grows  som- 
nolent, apathetic  and  semicomatose.  Death  comes  on  either  in  deeper  coma 
and  exhaustion,  or  preceded  by  an  acute  exacerbation  of  the  symptoms,  with 
convulsions,  coma  and  paralysis. 

Groups  of  Symptoms. — Having  thus  sketched  the  clinical  evolution  of 
the  principal  forms  of  uremia,  we  should  now  consider  more  in  detail  the 
individual  groups  of  symptoms  observed  in  this  condition.  Many  signs  of 
uremia  occur  in  other  conditions  and  it  is  for  this  reason  that  the  diagnosis 
of  uremia  is  not  easy  to  make.  In  each  case,  a  careful  study  of  the  mass 
of  symptoms  is  needed.  The  clinical  picture,  however,  can  usually  be  sub- 
divided into  various  groups  or  classes  of  symptoms,  one  or  more  being  repre- 
sented in  the  case  studied : 

(1)  NERVOUS    SYMPTOMS. 

Headaches. 
Neuralgias. 
Disturbances     of     cutaneous     sensation,     e.  g.,     tingling,     formication, 

"  dead  finger." 
Restlessness,  confusion  of  ideas,  partial  aphasia,  somnolence,  disturbed 

sleep,  aj)athy,  depression,  convulsions,  delirium,  coma,  paralyses. 

(2)  CARDIO-RESPIRATORY    SYMPTOMS. 

Dyspnea. 
Uremic  asthma. 
Cheyne-Stokes  breathing. 

Bronchitis,  pleurisy,  pulmonary  edema,  hydrothorax. 
Heart  symptoms,  due  to  affection  of  the  heart  which  may  coexist.     Usu- 
ally cardiac  hypertrophy  and  increased  arterial  tension, 

(3)  GASTRO-INTESTINAL    SYMPTOMS. 

(a)   Mouth  and  Pharynx: 

Dryness,  thirst,  difiiculty  in  swallowing. 
Stomatitis  (catarrhal  or  ulcerative). 
Salivation. 


444  UEEMIA 

(h)   Stomach: 

Anorexia,  djsjx'psia. 

l^aiisea  or  vomiting'. 
(c)    Intestines: 

])iarrliea   (serous  or  dysenteric),  constipation. 

(■i)     SKIN     SYMPTOMS. 

Pruritus. 

Erythema  papulosuni  and  maculusuni. 

Urticaria,  purjjura. 

Hyperidrosis. 

(5)  EYE    SYMPTO:iIS. 

Miosis  (contracted  pui:)ils  ),  mydriasis. 
Disturbances  of  vision,  double  vision,  amaurosis. 
Optic  neuritis. 

(6)  EAR    SY'MPTOMS. 

Tinnitus  (ringing)  or  other  noises  in  the  ear. 
Deafness  (sudden). 

(7)  URINAEY"    SY'MPTOMS. 

Oliguria  or  anuria  in  acute  form. 

Quantity  normal  or  increased  in  chronic*  forms  (but  quality  suffers). 

Urea  diminished. 

Albumin  usual  (not  invariably  present). 

Functional  efficiency  of  kidneys  low  (cryoscopy,  phloridzin  test,  etc.). 

(8)  GENERAL    SY'MPTOMS. 

Emaciation,  atrof)hy  of  muscles,  edema. 
Pulse  slow,  high  tension. 
Temperature  subnormal  or  febrile. 

Nervous  Symptoms. — Some  of  these  are  characteristic  of  the  prodromal 
period.  The  uremic  headache  is  one  of  the  early  symptoms,  and  is  usually  very 
obstinate,  sometimes  occurring  in  the  form  known  as  migraine.  Headache,  ac- 
companied by  apathy  and  stupor,  may  also  be  present  during  the  attack  itself. 

A  variety  of  neuralgias  often  depend  upon  incipient  uremia.  These  include 
particularly  occipital  neuralgias  and  angina  pectoris.  Pains  in  the  limbs  and 
joints  and  disturbances  of  sensibility  may  also  occur  as  prodromal  signs. 

During  the  attacks  of  uremia,  the  serious  nervous  symptoms  may  be  divided 
into  the  signs  of  excitement  and  those  of  depression.  The  former  include  con- 
vulsions which  may  assume  the  type  of  eclampsia  or  e]ulepsy,  general  or  par- 
tial clonic  contractions,  which  are  the  usual  types.  These  convulsions  present 
nothing  specially  characteristic,  and  the  differential  diagnosis  from  epilepsy, 


SYMPTOMS  445 

etc.,  must  1)0  made  from  doliriiim,  coma  and  tlie  other  symptoms  above 
iiiciitidiicd. 

Delirium  is  another  symptom  of  this  gronp.  The  patient  may  suffer  from 
confusion  of  ideas,  mutter  incoherent  sentences,  and  have  illusions  and  hallu- 
cinations. In  other  patients,  the  delirium  seems  to  be  more  specific  in  char- 
acter— they  rave  about  one  subject,  often  2:)ersecution,  or  they  become  moody 
and  melancholy  and  may  attempt  suicide. 

Coma  is  one  of  the  most  typical  symptoms  of  the  uremic  attack.  In  the 
acute  form,  it  comes  on  rapidly,  in  the  chronic  form  more  gradually,  l)ur  in 
both  the  same  features  prevail  as  a  rule.  It  is  accompanied  by  anuria  or  oli- 
guria, a  subnormal  temperature,  a  slow  pulse,  slow,  irregular  breathing  (Cheyne- 
Stokes).  The  muscles  are  completely  flaccid,  the  face  is  pale,  the  pupils  con- 
tracted and  consciousness  is  entirely  lost. 

Paralyses  have  been  observed  in  a  large  number  of  cases  of  uremia,  espe- 
cially those  due  to  chronic  nephritis.  They  vary  in  intensity,  and  disappear 
if  the  patient  recovers.  The  affected  muscles,  usually  those  of  one  arm,  are 
always  perfectly  flaccid.  Occasionally  aphasia  has  been  observed  in  these 
cases. 

Bespiraiory  Symptoms. — The  dyspnea  of  uremia  may  be  either  toxic  or 
pulmonary.  The  toxic  form  occurs  after  exertion  and  overeating.  It  is  easily 
cured  by  simply  adopting  a  milk  diet.  Typical  asthmatic  symptoms  accompany 
the  dyspnea.  The  jjatient  is  unable  to  lie  down  in  bed,  and  complains  of  constant 
oppression  on  his  chest,  breathes  srapidly  and.  emits  sibilant  rales.  The  attacks 
come  on  at  uight,  without  asphyxia. 

In  another  type  of  cases,  there  is  actual  asphyxia  associated  with  the  dysp- 
nea, and  the  patient  may  die  during  the  attack. 

Cheyne-Stokes  breathing  is  an  abnormal  type  of  respiration  not  characteris- 
tic of  uremia,  but  present  during  the  attacks,  in  the  comatose  stage.  The 
extent  and  rapidity  of  the  respiratory  movements  are  gradually  lessened,  until 
the  patient's  breathing  is  entirely  arrested  for  several  seconds  ;  it  is  then  resumed 
again  at  a  gradually  increasing  rate  and  depth.  It  is  always  a  serious  symp- 
tom, pointing  to  deep  involvement  of  the  cerebrum. 

Bronchitis,  pulmonary  edema  and  hydrothorax  may  accompany  uremia  and 
give  rise  to  pulmonary  dyspnea.  Pulmonary  edema  is  often  a  fatal  complication 
of  uremia. 

Gasfro-intestinol  Symptoms. — In  acute  uremia,  vomiting  is  a  frequent 
and  important  symptom,  but  the  chronic  uremic  state  may  show  many  more 
signs  on  the  part  of  the  gastro-intestinal  tract,  including  all  those  mentioned  in 
the  table.  The  toxic  agents  causing  uremia  are  evidently,  at  least  in  part,  elimi- 
nated through  the  mucosa  of  the  gastro-intestinal  tract,  instead  of  through  the 
insufficient  kidneys,  and  accordingly  the  entire  tube  from  mouth  to  rectum  may 
be  affected.      Dryness  of  the  tongue  and   throat  and  thirst   are  frequent  pre- 


446  IJEEMIA 

monitory  symptoms  of  a  uremic  attack.     (Stomatitis  is  rare,  but  must  Le  looked 
out  for. 

The  vomiting  at  first  occurs  after  meals;  later  it  is  more  frequent  and 
occurs  independently  of  eating.  The  vomited  matter  contains  urea  and  am- 
monium carbonate  and  is  alkaline  in  reaction.  Under  these  circumstances,  vom- 
iting is  a  grave  sign,  showing  that  the  toxemia  is  general  and  profound,  and  the 
renal  insufficiency  very  marked,  so  that  the  organism  has  recourse  to  emesis 
to  rid  itself  of  the  accumulated  poisons. 

Usually,  the  diarrhea  is  of  the  ordinary  catarrhal  or  muco-serous  type,  fre- 
quent fetid  fluid  stools  being  the  chief  symptom.  There  are  cases,  however, 
in  which  intestinal  ulceration  leads  to  a  dysenteric  diarrhea.  Alternate  consti- 
pation and  diarrhea  are  often  present. 

Eye  Symptoms. — The  ocular  symptoms  of  uremia  should  l)e  carefully  dis- 
tinguished from  those  of  chronic  nephritis.  The  former  are  not  accompanied 
by  ophthalmoscopic  changes ;  the  visual  disturbances  are  of  sudden  onset  and 
transitory  in  character  (double  vision,  hemiopia,  hemeralopia,  amblyopia  and 
amaurosis).  At  the  height  of  a  seizure,  the  pupils  are  dilated  and  do  not  react 
to  light  or  only  feebly  so,  whereas  a  chronic  uremic  poisoning  not  an  attack 
produces  a  contraction  of  the  pupil.  Edema  of  the  optic  sheath  has  been  noted 
in  cases  where  the  pupils  fail  to  react.  The  presence  of  an  albuminuric  retinitis 
is  shown  by  the  ophthalmoscope.  Amaurosis,  always  bilateral,  may  be  the  only 
symptom  of  uremia  in  certain  exceptional  cases,  and  in  conjunction  with  head- 
ache is  often  the  forerunner  of  an  attack. 

Urinary  Symptoms. — The  urinary  symptoms  of  uremia  vary  according  to 
the  original  cause  of  this  condition  in  a  given  case.  The  quantity  of  urine  ex- 
creted is  greatly  diminished  (oliguria),  or  there  is  total  absence  of  urinary  se- 
cretion (anuria)  in  acute  forms,  due  to  acute  parenchymatous  nephritis,  to  an 
acute  exacerbation  of  a  chronic  parenchymatous  nephritis,  or  to  acute  obstruc- 
tion of  the  urinary  tract. 

In  chronic  interstitial  nephritis,  on  the  other  hand,  there  is  an  increased 
amount  of  urine  (polyuria)  of  low  specific  gravity.  The  amount  of  urea  is 
generally  diminished  considerably,  the  daily  excretion  becoming  less  and  less 
in  the  fatal  cases  until  it  reaches  zero  at  death.  Usually  there  is  some  albumin, 
but  this  may  be  absent.  The  functional  efficiency  of  the  kidney  as  tested  by  the 
cryoscope,  the  phloridzin  test  and  other  means  is  very  much  impaired,  especially 
in  uremias  due  to  interstitial  nephritis. 

Among  the  clinical  urinary  symptoms,  nothing  characteristic  of  uremia  can 
be  noted.  There  may  be  frequency  of  urination,  retention  with  overflow,  in- 
continence and  a  musty  odor  of  dribbling  urine  soaking  into  the  bedclothes. 
These  symptoms  depend  upon  the  primary  condition  of  the  urinary  organs,  in- 
ducing uremia,  the  presence  of  renal  or  vesical  infection,  urinary  obstruc- 
tion, etc. 


DIAGNOSIS  447 

In  the  comatose  condition  of  uremia,  retention  of  the  nrine  may  occur  from 
inability  to  feel  the  impulse  to  urinate.  In  such  cases,  the  urine  either  dribbles 
away  as  the  bladder  overflows,  or,  if  the  coma  is  not  so  profound,  the  patient 
voids  the  entire  contents  of  the  bladder  involuntarily  at  intervals.  Of  course, 
this  does  not  refer  to  the  urinary  retention  due  to  obstruction  which  may  and 
fr('([uently  does  appear  with  uremia,  especially  uremia  as  it  comes  to  the 
knowledge  of  the  surgeon.     (Compare  sections  on  Incontinence  and  Retention.) 

General  Symptoms. — Acute  uremia  may  occur  in  apparen1:ly  perfectly 
healthy  persons.  Chronic  uremia,  with  its  attendant  renal  insufficiency  and 
gastro-intestinal  troubles,  leads  to  pallor,  emaciation,  cachexia  and  weakness  of 
the  muscles,  which  become  atrophied.  Edemas  may  be  present,  especially  in 
patients  with  cardiac  complications  and  cirrhosis  of  the  liver. 

The  pulse  of  uremia  is  characteristically  slow  and  of  higb  tension.  This  is 
the  result  of  the  intoxication  and  of  the  condition  of  the  arteries  in  chronic 
nepliritis.  High-tension  pulse  in  a  nephritic  is,  indeed,  considered  by  some  as 
a  sign  of  impending  uremia,  although  fatal  uremias  may  be  accompanied  by  a 
comparatively  low  arterial  tension. 

The  temperature  during  the  attack  tends  to  become  subnormal  as  the  symp- 
toms increase  in  gravity.  Fever  may,  however,  be  present  if  there  is  an  infec- 
tion of  the  kidney  or  any  other  organ,  and  also  in  some  of  the  acute  cases,  due 
to  acute  nephritis. 

Diagnosis. — A  correct  interpretation  of  a  given  symptom  as  a  sign  of  uri- 
nary intoxication  is  not  always  easy.  A  symptom  may  be  looked  upon  as  uremic 
in  origin,  (a)  when  it  is  associated  w^ith  other  signs  pointing  to  uremia;  (b) 
when  it  occurs  without  any  organic  basis  of  disease  in  the  organ  with  which 
the  symptom  is  associated  (e.  g.,  the  stomach  and  the  intestine)  ;  (c)  when  it  is 
associated  with  renal  disease,  alone  or  in  combination  with  lesions  of  the  lower 
genito-urinary  tract.  A  careful  examination  of  the  urinary  organs  and  of  the 
urine  is  essential  for  a  diagnosis  of  uremia. 

If  there  is  no  residual  urine  in  the  bladder,  no  obstruction  to  the  discharge 
of  urine,  no  oliguria  or  anuria,  and  if  a  fresh  specimen  and  a  twenty-four-hours' 
specimen  of  urine  are  found  to  indicate  normal  function  of  the  kidney,  the 
symptom  thought  to  be  uremic  in  origin  must  be  ascribed  to  some  other  cause. 

On  the  other  hand,  uremia  is  diagnosticated  by  the  presence  of  the  symp- 
toms or  groups  of  symptoms  above  described,  when  the  urine  shows  a  deficient 
renal  function. 

For  the  purpose  of  obtaining  an  estimate  of  the  kidney  function,  we  resort 
to  the  methods  of  functional  diagnosis  described  in  detail  in  the  chapter  on 
Examination  of  the  Kidney.  Of  these,  the  most  valuable  in  the  diagnosis  of 
uremia  are  the  determination  of  the  specific  gravity,  of  the  total  solids  ex- 
creted, of  the  percentage  of  urea  of  the  total  nitrogen  in  the  urine  and  the 
measurement  of  the  freezing  points  of  the  urini'  and  of  the  blood  (cryoscopy). 


448  UREMIA 

The  retention  of  toxic  snbstances  in  tlie  hhnn]  and  the  deficiency  of  elimina- 
tion of  these  substances  by  the  kidneys  are  expressed  in  nreinia  l)y  (1)  a  hnv- 
ered  specific  gravity;  (^)  a  diminished  amount  of  total  solids  excreted  in  twen- 
ty-four hours;  (3)  a  low  percentage  of  urea  and  of  nitrogen;  (4)  a  lowered 
freezing  point  of  the  blood,  owing  to  its  greater  concentration;  and  (5)  a  raised 
freezing  point  of  the  urine  (nearer  zero,  owing  to  the  lowei-ed  concentration). 

Differential  Diagnosis  of  an  Attack  of  Uremia. — Uremic  unconsciousness 
Coming  on  suddenly,  as  in  chronic  interstitial  nephritis,  may  simulate  (1)  cere- 
bral hemorrhage,  (2)  meningitis,  (3)  epilepsy  and  (-4)  certain  intoxications, 

(1)  Cerebral  Hemorrhage. — In  apoplexy,  which  is  so  commonly  asso- 
ciated Avith  kidney  disease  and  arteriosclerosis,  the  sudden  loss  of  consciousness 
may  simulate  a  uremic  attack ;  but  the  mode  of  onset  as  well  as  the  existence  of 
complete  hemiplegia,  with  the  eyes  turned  toward  the  lesion  and  away  from 
the  paralyzed  side,  suggest  cerebral  hemorrhage.  The  distinction  is  extremely 
difficult,  if  not  impossible  in  certain  cases. 

(2)  Meningitis. — Meningitis,  in  which  there  is  deep  coma,  with  rise  of 
temperature,  a  furred  tongue  and  no  localizing  symptoms,  is  also  easily  con- 
founded with  uremia ;  but  the  mode  of  onset,  the  rigidity"  of  the  neck,  inco- 
herence or  mild  delirium,  photophobia  and  pronounced  fever,  point  to  a  lesion 
of  the  brain. 

(3)  Epilepsy. — The  fulminating  or  eclamptic  type  of  uremia  is  very  sug- 
gestive of  epilepsy.  The  principal  distinctive  feature  between  uremia  and 
epilepsy  is  that  uremic  attacks  are  usually  preceded  by  headache,  vertigo  and 
nausea,  and  occur  without  an  injury  to  the  tongue.  The  onset  of  an  epileptic 
attack  is  sudden,  with  tonic  and  then  clonic  convulsions,  beginning  generally 
with  biting  of  the  tongue.  A  history  of  former  seizures  is  sometimes  obtain- 
able. The  urine  during  and  after  a  paroxysm  of  epilepsy  may  contain  albu- 
min. When  the  convulsions  are  uremic,  albumin  and  casts  may  both  be  present. 
Edema,  especially  under  the  eyes,  would  point  to  uremia.  The  ophthal- 
moscopic examination  of  a  uremic  patient  would  show  degenerative  changes  in 
the  retina. 

(4)  Intoxications. — Uremic  coma  may  be  mistaken  for  poisoning  by 
opium  or  alcohol.  In  opium  poisoning  the  pupils  are  contracted,  whereas,  in 
an  attack  of  uremia,  they  are  dilated.  According  to  the  type  of  uremia,  the 
pupils  may  be  either  widely  dilated,  of  mediinn  size  or  contracted,  but  in  a  so- 
called  attack  of  uremia,  when  a  diagnosis  is  most  important,  they  are  dilated, 
the  contracted  pupil  being  characteristic  of  chronic  cases.  The  examination  of 
the  ocular  fundus  with  the  ophthalmoscope,  to  determine  the  presence  or  ab- 
sence of  albuminuric  retinitis,  is  a  valuable  diagnostic  adjuvant.  The  urine 
should  be  drawn  oif  and  examined  in  all  suspected  cases. 

In  the  diiferential  diagnosis  of  uremia  from  alcoholism  (state  of  drunken- 
ness), an  alcoholic  odor  of  the  breath  sometimes  is  a  most  important  point.     In 


PROONOSTS  449 

nlroliolip  intoxication,  tlio  pnpils  arc  soniewliat  dilated,  l)iit  not  as  markedly  as 
ill  iirciiiia.  The  condition  of  the  heart  and  arteries  must  also  be  taken  into 
account  in  cases  of  elderly  individuals  who  may  be  suffering  from  arterioscle- 
rosis. The  delirium  in  alcoholism  is  not  accompanied  by  convulsions,  and  the 
coma  is  not  so  deep  as  in  uremic  poisouing.  Tt  may  for  a  time  be  impossible 
to  determine  whether  the  condition  is  du(>  to  uremia  or  to  profound  alcoholism, 
as  one  of  the  ])rincipal  causes  in  precipitating  an  attack  of  uremia  in  a  nephritic 
is  overindulgence  in  alcohol.  In  many  of  these  doid)tful  cases,  uremia  can  be 
identitied  by  the  history  given  by  the  family,  the  age  of  the  patient  and  the 
marked  arterial  tension.  The  presence  of  dropsy  in  some  cases  is  a  valuable- 
indication  of  the  nephritic  origin  of  uremic  symptoms. 

Uremic  coma  must  also  be  differentiated  from  diabetic  coma.  The  examina- 
tion of  the  urine  would  show  the  presence  of  sugar  and  further  tests  with  the 
tinctu.re  of  the  chlorid  of  iron  would  show  the  Burgundj^-red  reaction  of 
acetone. 

Acute  Prolonged  Uremia. — The  differentiation  of  uremia  from  certain 
infectious  diseases  is  sometimes  difficult.  The  uremia  may  persist  for  weeks 
or  months,  the  patient  lying  in  a  condition  of  torpor  or  even  unconsciousness 
and  slight  fever,  with  a  heavily  coated  and  also,  perhaps,  dry  tongue,  a  rapid 
feeble  pulse  and  muscular  twitchings.  This  state  naturally  suggests  the  ex- 
istence of  one  of  the  infectious  diseases,  such  as  typhoid  fever  or  acute  miliary 
tuberculosis. 

There  is  no  absolute  rule  applicable  to  the  differential  signs.  The  table 
(page  450)  which  I  have  written  out  is  appended,  simply  as  an  aid  in  doubtful 
cases. 

Prognosis. — Uremia,  once  diagnosticated,  should  always  be  a  source  of 
anxiety  to  the  attendants  of  the  patient,  because  there  is  an  element  of  uncer- 
tainty in  the  manner  in  wdiich  the  intoxication  will  affect  a  given  case.  A 
peculiarity  of  uremia,  which  should  not  be  overlooked  in  making  a  prognosis, 
is  that  the  degree  of  actual  intoxication  and  the  severity  of  the  symptoms  do 
not  always  correspond  with  the  gravity  of  the  lesions  in  the  renal  apparatus. 
In  some  patients,  the  subjective  and  even  the  objective  symptoms  may  be  quite 
severe,  while  the  renal  function  is  very  fair ;  wdiereas,  others  exhibit  remark- 
ably few  and  mild  symptoms  with  very  much  impaired  renal  functions. 

The  type  of  uremia  has  no  xerj  pronounced  bearing  on  the  prognosis,  Tlie 
mild  latent  form  nuiy  exist  for  years,  but  eventually  the  grave  form  develops. 
The  chronic  form  toward  the  end  may  become  more  and  more  severe,  the  at- 
tacks increasing  in  frequency,  until  one  of  them  ends  in  death.  The  acute  form 
may  either  subside  and,  if  its  cause  be  removed,  leave  the  patient  in  good 
condition,  or  it  may  end  fatally,  or  it  may  dcvclo])  into  llic  clirduic  fonii. 

The  cause  of  death  may  ])c  one  of  the  following:  (  1)  Hearh  in  coma,  some- 
times following  convulsions ;  (2)  edenux  of  the  lungs ;  (3)  asthenia. 


450 


UREMIA 


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TREATMENT    OF   UPwEMTA 


451 


A  case  which  occurred  in  one  of  my  hospital  services  was  in  a  boy  aged 
twenty-one  years,  who  had  total  suppression  of  urine  and  lived  for  eight  days 
after  the  removal  of  a  large  tuberculous  kidney.  At  no  time  during  the  post- 
operative eight  days  did  he  show  any  signs  of  uremia  and  was  conscious  almost 
to  the  end.  Death  occurred  from  astlienia.  The  autopsy  revealed  the  absence 
of  a  second  kidney. 

Treatment  of  Uremia. — Wlien  convulsions  are  frequent,  the  face  red  and 
cyanotic,  the  pulse  full,  venesection  is,  in  my  judgment,  the  most  effective 
remedy.  The  causes  of  the  benefit  derived  from  venesection  are  probably  four : 
(1)  Withdrawal  of  a  part  of  the  poisons  circulating  in  the  blood;  (2)  lowering 


Fig.  280. — Bleeding  the  Patient  in  Uremia.     (See  also  Figs.  258,  259,  260.) 

of  the  blood  pressure;  (3)  dilution  of  the  blood,  i.e.,  lessening  the  viscosity, 
and  hence  a  reduction  of  the  work  of  the  heart  and  of  friction  along  the  vessels ; 
and  (4)  the  lowering  of  temperature  (Fig.  280).  It  is  usually  followed  by  an 
intravenous  injection  of  a  corresponding  quantity  of  normal  salt  solution.  (See 
Intravenous  Injections  of  Saline  Solution  in  chapter  on  the  Use  of  Water  in 
Urology. ) 

The  subject  of  the  lessening  of  the  viscosity  of  the  blood  brings  us  next  to 
the  employment  and  effect  of  inhalations.  By  this  easy  means,  agents  that 
enter  the  blood  rapidly  may  be  given,  with  a  notable  effect  upon  the  convulsions 
when  present.  Chloroform  is  among  the  first,  a  few  whiffs  lessening  the  motor 
symptoms  in  a  marked  manner. 

For  the  dyspnea,  iodid  of  ethyl  may  be  inhaled  with  relief,  from  a  small 
vial  held  in  the  hand,  or  ten  to  twenty  minims  on  a  handkerchief.  The  internal 
administration,  of  morphin  and  heroin  markedly  relieves  the  dyspnea  and  the 
convulsions.  When  the  convulsions  are  marked  liy  high  tcusidu,  the  vaso-di- 
lators,  glonoin  or  spirits  of  nitroglycerin  (2  to  5  dro^is  every  three  to  four 
hours),   amyl  nitrite    (trt   v   from   a   crushed   capsule),   cautiously    inhaled,    is 


452  UREMTA 

sometimes  employed,  nnd  iimst  bo  regarded  witli  favor  under  the  proper 
conditions. 

Ammonia,  a  remedy  too  little  nsed,  exerts  a  direct  liquefying  action  upon 
the  blood,  reducing  its  molecular  concentration,  and  contributing  to  the  oxida- 
tion of  other  nitrogenous  compounds.  The  aromatic  spirits  of  ammonia  (thirty 
to  sixty  minims  in  water)  are  serviceable,  stimulating  the  movements  of  the 
stomach  and  intestines.  In  the  most  pressing  cases,  ammonia  can  Ije  injected 
directly  into  a  vein  of  the  leg. 

In  an  acute  attack  of  uremia,  there  often  are  symptoms  of  approaching 
weakness  of  the  heart,  a  snuill  pulse,  so  small  at  times  as  to  be  imperceptible,  and 
very  faint  respiration.  Under  these  circumstances,  the  aromatic  spirits  of 
ammonia  are  very  useful,  and  it  may  be  well  to  support  the  heart  with  injec- 
tions of  digitoxin,  yro  grain ;  camphor,  14  grain  in  oil ;  caifein  sodium  salicyl- 
ate, -|  to  2  grains ;  and  etlier,  f3ss  or  more  in  cold  water.  After  venesection, 
isotonic  injections  of  warm  saline  solution  into  the  veins  or  into  the  loose  cel- 
lular tissue  of  the  flanks,  groin  and  axilla,  are  given. 

In  all  cases  of  acute  uremia,  an  effort  should  be  made  not  to  overtreat  the 
patient  by  too  violent  purging,  which  is  very  exhausting  and  often  not  as  effi- 
cacious as  the  milder  methods  above  mentioned,  or  the  simple  diuretics  and 
dieting.  As  to  the  convulsions,  there  are  no  better  remedies,  if  swallowing  is 
possible,  than  the  bromids. 

The  treatment  of  chronic  uremia  is  considered  under  Chronic  Xephritis. 


CHAPTER    XXV 

CHRONIC   SUPPURATIVE   DISEASES   OF  THE  KIDNEY 

(Pyelitis,  Pyelo-nephritls,  Pyonephrosis,  PerinepJnitic  Abscess,  Nephritic  Ah- 
■     sccss  and  Suppurative  Nephritis) 

During  the  last  two  decades,  there  have  been  rapid  changes  in  our  views  of 
the  pathology  and  bacteriology  of  the  kidney,  due  principally  to  the  exhaustive 
investigation  of  the  French  school. 

Xotwithstanding,  however,  that  much  light  has  been  throAvn  upon  the  causes 
of  these  diseases,  the  variety  and  manner  of  infection,  their  scope  and  line  of 
march,  the  clinician  is  still  constantly  at  a  loss  to  know  in  any  case  before  him 
whether  one  of  these  affections  exists  alone,  or  whether  two  or  more  are  com- 
bined. The  diseases  of  this  variety,  however,  that  have  come  under  my  per- 
sonal observation,  were  usually  combined,  instead  of  existing  as  one  single,  well- 
defined  disorder. 

I  may  here  say,  in  a  general  way,  that  I  consider  the  diseases  closely  asso- 
ciated with  one  another  in  their  line  of  march  to  be :  Pyelitis — an  inflammation 
of  the  pelvis  of  the  kidney ;  pyelo-nephritis — a  pyelitis  plus  nephritis ;  pyo- 
nephrosis— a  pyelitis  plus  a  nephritis,  together  with  enlargement  of  the  pelvic 
cavity  due  either  to  destruction  of  renal  tissue  by  abscess,  or  to  dilation  of  the 
pelvis  from  obstructions  lower  down  the  canal,  or  to  both  these  causes ;  and  peri- 
nephritic  abscess — a  collection  of  pus  about  the  kidney.  Abscess  of  the  kidney 
and  suppurative  nephritis  occurring  independently  of  the  above  group,  will  he 
considered  later.     They  are  comparatively  rare. 

As  the  scope  of  this  work  is  clinical,  I  will  endeavor  to  consider  these  dis- 
eases from  a  clinical  standjioint,  whatever  may  be  their  etiology.  I  will,  there- 
fore, include  in  this  consideration  tuberculosis  and  calculus,  as  they  have  been 
in  my  practice  such  frequent  predisposing  causes  of  renal  suppuration. 

PYELITIS 

Etiology. — The  causes  of  these  sup]iurativc  diseases  of  the  kidney  arc  prac- 
tically the  same,  whether  the  inflannnation  begins  in  the  pelvis  and  extends  to 
the  parenchyma,  or  whether  it  begins  in  the  parenchynui  and  extends  into  the 
pelvis.     They  are  predisposing  and  active  causes.     The  former  include,  in  the 

453 


454  CHRONIC    SUPPURATIVE    DISEASES    OF    THE    KIDNEY 

first  place,  debilitated  conditions  of  the  Inxly  which  favor  suppuration;  infec- 
tious diseases;  any  factor  Icadini;-  to  congestion,  as  traumatism  from  direct  con- 
tusion; the  irritation  of  drugs,  exposure  to  cold  or  wet  and  displacement  of  the 
kidney  due  to  great  mobility. 

Other  ])redisposing  causes  are  found  in  all  conditions  which  interfere  with 
the  urinary  flow  or  congest  or  irritate  the  kidney ;  in  the  first  instance — urethral 
strictures;  enlarged  prostate;  vesical  stone  or  tumor;  ureteral  stone,  tulierculosis 
or  stricture;  or  outside  pressure  upon  the  ureter  due  to  adhesions  or  growths: 
and  in  the  second  instance — a  stone ;  tumor ;  tuberculosis  of  the  kidney  or  its 
pelvis;  or  abnormal  renal  mol)ility. 

In  tuberculosis  with  suppuration,  the  pelvis  may  l)e  involved  in  an  ascend- 
ing process  from  the  bladder  or  in  a  descending  process  from  the  kidney  tis- 
sues, usually  the  latter.  The  tubercles  developing  in  the  renal  pelvis  may  break 
down  and  suppurate  at  the  same  time  that  a  similar  process  is  going  on  in  the 
kidney  proper. 

Usually  pyelitis  is  a  part  of  a  pyelo-nephritis  or  pyonephrosis,  and,  in  most 
cases  in  wdiich  the  predisposing  cause  of  the  pyelitis  is  not  removed  or  relieved, 
the  disease  secondarily  affects  the  kidney,  at  least  in  its  medullary  portion : 
whereas,  on  the  other  hand,  in  the  great  majority  of  cases  in  which  the  su})- 
purative  process  begins  in  the  parenchyma,  the  inflammation  in  turn  extends  to 
the  pelvis. 

The  active  causes  of  these  suppurative  conditions  are  the  various  pus-produc- 
ing germs,  the  most  common  of  which  are  the  colon  bacillus,  staphylococcus, 
streptococcus,  Proteus  vulgaris.  Bacillus  pyocyaneus.  The  gonococcus  is  a  pus 
producer,  but  it  is  rarely  the  active  microorganism  giving  rise  to  the  renal  su])- 
puration.  The  tubercle  bacillus  is  not  considered  as  a  pus  producer,  but  is 
productive  of  lesions  that  are  favorable  for  other  infections. 

The  infectious  agents  that  produce  renal  suppuration  may  reach  the  organ 
either  through  the  Idood  (hematogenous  infection)  or  through  the  lymph 
(lymphogenous  infection),  or  they  may  reach  the  organ  by  extension  of  the 
suppuration  from  neighljoring  structures  (infection  by  contiguity),  and  finally 
the  infection  may  travel  upAvard  from  some  lower  portion  of  the  genito- 
urinary tract,  as  the  urethra  or  bladder  (ascending  infection,  or  infection  by 
continuity. 

The  ureteral,  lymphogenous  and  heumtogenous  routes  of  these  infectious 
have  been  carefully  investigated  by  All)arran  and  others  of  the  Xecker  school, 
who  have  concluded  that  the  circulatory  is  the  most  common.  Pus-producing 
microorganisms  in  the  blood  current  circulating  through  the  kidney  or  its  pelvis 
are  not  likely  to  give  rise  to  sup})uration  without  the  presence  of  congestion  due 
to  some  of  the  predisposing  causes  just  mentioned ;  but  if  congestion  is  present, 
the  germs,  having  passed  through  the  circulation  and  entered  the  urinary  tract, 
find  the  pelvis  a  soil  adaj)ted  for  their  settlement  and  gTOwth. 


I 


PYELITIS  455 

We  have,  therefore,  covered  the  causes  of  this  group  of  diseases  in  a  general 
way,  and  those  of  pyelitis  in  particidar. 

Pathology. — Pyelitis  usually  begins  with  a  simple  catarrhal  condition  of 
the  mucous  membrane  of  the  pelvis,  with  congestion  of  the  superficial  capil- 
laries and  an  excess  of  mucus.  As  infection  takes  place,  the  mucous  membrane 
takes  on  the  appearance  of  a  turbid  gelatinous  lining,  which  is  rapidly  fol- 
lowed by  a  purulent  exudate  and  thickening  of  the  wall.  The  thickening  and 
roughness  of  the  pelvic  wall  are  more  marked  in  tubercular  cases  and  the  ulcera- 
tions are  of  a  more  active  type.  There  is  also  great  thickening  at  times  in  cal- 
culous pyelitis,  as  well  as  erosions  and  capillary  hemorrhage. 

When  the  pyelitis  is  due  to  an  ascending  infection,  there  is  a  gi'eater  dilata- 
tion of  the  pelvis,  its  surface  is  smoother  and  thinner  and  the  capillary  conges- 
tion is  less.  The  amount  of  urine  and  pus  is  considerable  and  the  admixture 
thinner  than  in  the  descending  cases.  Capillary  congestion,  engorgement,  ero- 
sions and  ulcerations  are  also  less  marked.  It  must  be  remembered  that  urinary 
retention  takes  place  in  varying  degrees  when  there  is  obstruction  due  to  tuber- 
cular lesions  or  calculus,  but  that  the  retention  is  greater  when  there  is  obstruc- 
tion due  to  interference  with  the  urinary  flow  in  the  ureter  proper. 

When  the  pyelitis  advances  to  such  a  degi'ee  that  there  is  retention  of  urine 
and  pus  in  the  renal  pelvis,  the  parenchyma  is  also  generally  involved  and  the 
trou1)le  l)econies  a  pyelo-nephritis  or  pyonephrosis. 

Symptoms. — The  symptoms  of  pyelitis  are  few  and  at  times  absent  when  it 
exists  alone  and  not  associated  with  calculus,  tumor,  tuberculosis  or  abnormal 
renal  mobility.  There  is  sometimes  slight  frequency  of  urination,  due  to  a 
polyuria,  or  there  may  be  a  vague  pain  or  a  heavy  feeling  in  one  or  both  loins. 
The  pain  is  more  intense  and  colicky  when  the  pyelitis  is  due  to  calculus  or  to 
movable  kidney.  Plematuria  is  rare  in  pyelitis  unless  there  is  a  growth  or  stone 
present,  when  it  is  common ;  whereas,  in  tuberculosis  it  is  still  less  frequent. 
Pyuria  exists,  but  is  of  a  mild  degree  when  the  pelvis  is  alone  involved ;  but 
when  a  cystitis  also  is  present,  the  pyuria  is  more  marked,  owing  to  the  addition 
of  the  pus  produced  in  the  bladder  to  that  coming  from  the  pelvis  and  ureter. 
Marked  frequency  of  urination  is  due  to  an  associated  cystitis,  probably  tuber- 
cular. Attacks  of  nausea,  vomiting,  chills,  fever  and  sweating  are  generally 
due  to  movable  kidney  or  renal  calculus,  with  attacks  of  retention  and  absorption 
of  ])us.  Febrile  attacks  also  ])(iiiit  to  an  extension  of  the  inflanunation  to  the 
kidne}'  substance  and  we  must,  therefore,  always  be  on  our  guard  against  such 
an  involvement. 

Examination. — In  pali)ating  the  kidney  in  ]\velitis,  a  slight  tenderness  may 
be  experienced  by  the  patient.  There  is  usually  no  rise  of  temperature.  There 
is  no  enlargement  of  the  organ  unless  a  complication  is  present,  such  as  retention 
of  ui'iue  and  ]ius  in  the  pelvis,  or  an  extension  to  the  kidney  parenchyma. 

The  urinary  examination  shows  in  the  chronic  cases,  such  as  are  usually  ob- 


456  CHRONIC    SUPPURATIVE   DISEASES    OF    THE   KIDNEY 

served,  a  urine  of  low  specific  gravity,  somowliat  increased  in  amount,  contain- 
ing considerable  pus,  scrum  and  nuclear  albumin,  pelvic  epithelia  and  a  few 
blood  cells  and  hyaline  and  granular  casts.  In  case  the  disease  is  due  to  tulier- 
culosis,  the  bacilli  may  be  found  in  the  urine ;  while  if  due  to  stone,  crystals 
may  be  found  in  masses  of  pus  and  mucus,  and  the  specific  gravity  is  higher. 

Diagnosis. — In  the  differentiation  of  pyelitis  and  cystitis,  there  are  some 
rather  interesting  points.  In  chronic  cystitis,  the  daily  amount  of  urine  and 
urea  are  always  normal,  unless  the  patient  has  been  given  a  large  amount  of 
water  or  diuretics.  The  reaction  is  generally  alkaline,  or  if  u'lt,  it  soon  be- 
comes so,  unless  due  to  the  colon  or  tubercle  bacillus.  The  amount  of  albumin 
does  not  exceed  that  caused  by  the  pus  and  blood.  There  is  a  muco-purulent 
sediment  which  coagulates  quickly.  ^Microscopically,  pus  and  a  large  number 
of  bladder  epithelial  cells  are  found  in  the  urine.  The  large  amount  of  ei)i- 
thelium  that  is  present  is  striking,  rather  than  any  particular  type.  There  is 
no  renal  pain,  nor  tenderness  on  pressure  over  the  kidney. 

In  chronic  pyelitis,  there  is  polyuria,  the  sediment  is  more  diffuse  and  does 
not  coagulate,  or  certainly  not  so  quickly.  The  urine  is  usually  acid  in  reaction 
and  contains  but  few  epithelial  cells.  The  importance  of  the  colon  bacillus  is 
not  sufficiently  appreciated ;  it  is  very  frequent  and  its  recog-nition  is  not  diffi- 
cult. A  cystoscopic  examination  will  always  give  information  concerning  the 
condition  of  the  bladder. 

ProgTiosis. — The  prognosis  of  pyelitis  depends  entirely  upon  its  cause  and 
the  j^resence  of  associated  lesions.  If  the  cause  is  removed,  the  patient  should 
recover.  This  may  require  some  time,  or  it  may  never  take  place,  in  which  lat- 
ter instance  the  pyelitis  ^vould  probably  slowly  extend  up  into  the  kidney  and 
develop  into  a  pyelo-nephritis  or  a  pyonephrosis.  In  many  cases,  the  kidney  is 
involved  together  with  its  pelvis,  but  the  couditi<ai  is  not  recognized. 

PYELO-NEPHRITIS 

Etiology. — The  etiology  of  pyelo-nephritis  is  the  same  as  that  of  pyelitis, 
as  it  is  either  an  extension  from  the  pelvis  up  the  straight  tubules  of  the  kidney, 
which  is  especially  the  case  in  obstructive  conditions;  or  from  above  do^^•nward, 
as  in  tuberculosis,  which  almost  always  begins  in  the  renal  parenchyma  and 
descends  to  the  pelvis.  In  saying  that  supjiurative  nephritis  is  secondary  to 
a  suppurative  pyelitis,  I  do  not  necessarily  mer.u  that  the  infection  must  come 
from  below  up  through  the  ureter  and  pelvis,  as  there  may  be  a  congestion  or 
nonsuppurative  nephritis  that  develops  during  a  i)yelitis  which  later  becomes 
a  septic  nephritis,  due  to  microorganisms  brought  to  the  kidney  through  the  cir- 
culation and  then  entering  the  urinary  tract. 

The  involvement  of  the  kidney  in  pyelo-nephritis  was  formerly  believed  to 
be  invariably  due  to  an  ascending  infection,  especially  after  traumatism  of  the 


PYELO-NEPHRITIS 


457 


nrctlira,  prostate  or  Lladdcr  in  passinc;  instruments  for  tlie  sake  of  examination 
ur  treat iiicnt  of  a  patient.  It  is  evident,  liowever,  tliat  in  the  event  of  erosions 
due  to  traumatism  in  passing  an  instrument,  absorption  of  the  pus  may  occur 
from  tliat  jiart  of  the  urinary  tract  where  the  lesion  is  situated,  and  the  infec- 
tion travel  through  the  circulation  to  the  kidnev.  In  fact,  in  cases  in  which  the 
predisposing  causes  to  pjelo-nephritis  exist,  either  as  ol)struction  or  irritation 
from  whatsoever  cause,  pus-producing  germs,  taken  into  the  circulation  from 
any  suppurative  focus  in  the  interior  or  on  the  exterior  of  the  body,  can  be 
carried  through  the  circulation,  to  the  kidney  and  cause  pyelo-nephritis. 

Patholog-y. — The  disease  is  usualh'  bilateral,  when  due  to  obstruction  in 
tlie  bladder,  prostate,  or  urethra,  but  the  kidneys  are  generally  not  eciually  in- 
volved ;  whereas,  in  cases  due  to  obstruction  of  a  single  ureter  or  renal  pelvis, 
the  trouble  is  unilateral.  As  far  as  the  renal  pelvis  is  concerned,  the 
])athology  of  pyelo-nejihritis  is  similar  to  that  of  pyelitis.  In  the  kidney, 
however,  the  process  is  usually  that  of  a  diffuse  nephritis  plus  pus.  In  other 
words,  the  parenchyma  of 
the  organ,  consisting  of  the 
tubules  and  the  glomeruli, 
is  involved  to  a  greater  or 
less  extent,  and  the  inter- 
stitial tissue  as  well.  The 
kidney  is  enlarged  in  most 
cases,  the  size  depending  up- 
on the  amount  of  inflamma- 
tion, abscess  formation  and 
exudate  about  the  abscesses 
and  their  cavities,  and  also 
on  the  dilatation  of  the  pel- 
vis. The  changes  in  the 
parenchyma  are  for  the  most 
])art  moderate,  although  there 
nuTy  be  areas  where  it  is  very 
much  involved.  In  certain 
localities,  there  are  greater 
inflannnatory  thickenings  of 
tlie  parenchyuui  than  in  oth- 
ers, and  here  abscesses  are 
more  liable  to  develop,  which 
usually  break  into  the  pelvis 
of  the  organ. 

ISTumerous  abscesses  may  be  found  in  the  kiihuy  in  pyelo-ne})hritis,  varying 
in  size  from  that  of  a  pea  to  a  marble.     They  are  more  frequent  in  cases  of 


Fig.  281. — Pyelo-nephriti.s. 


458  CHRONIC    SUPPURATTVE    DISEASES    OF    THE    KIDNEY 

tiibfrcul(»sis,  ill  wliicli  eases  the  disease  is  often  very  acute.  Abscesses  are  also 
frequent  in  some  cases  due  to  stricture  ami  enlarged  jn'ostate.  It  must  not  be 
thought,  however,  that,  in  stricture  and  enlarged  prostate,  the  pyelo-nephritis  is 
not  as  acute  as  in  tuljerculosis,  for  in  these  conditions  one  or  more  abscesses  may 
be  even  larger  than  those  in  tul)('rciilar  infection  of  the  kidney  (Fig.  281). 
Large  abscesses  also  occur  in  calculous  pyelo-nephritis. 

Having  made  a  section  through  the  convexity,  the  pelvis  is  seen  to  be  thick- 
ened and  congested  in  areas ;  there  may  be  some  erosions  or  superficial  ulcera- 
tions, and  the  surface  is  covered  with  pus,  the  same  as  has  been  described  under 
Pyelitis.  The  jDyramids  of  the  kidney  are  streaked  yellow  and  red.  The  yel- 
low streaks  may  also  be  seen  radiating  from  the  pyramids  into  the  cortex,  which 
constitute  a  feature  of  suppurative  pyelo-nephritis.  The  cortex  and  medul- 
lary portion  are  indurated  in  places  and  one  or  more  abscesses  may  be  seen 
there. 

On  squeezing  the  kidney,  pus  and  urine  may  be  expressed  from  the  collect- 
ing tubules  into  the  calices.  Large  areas  of  kidney  tissue  are  sometimes  found 
to  be  completely  destroyed,  occasionally  an  entire  pole  in  advanced  cases. 

The  microscopic  lesions  of  suppurative  pyelo-nepliritis  are,  in  the  order  of 
their  sequence,  an  exudation  of  leucocytes  into  the  renal  tubules  and  around  the 
glomeruli ;  a  diffuse  purulent  infiltration  of  the  parenchyma  with  gradual 
destruction  of  the  epithelium ;  an  increase  in  the  connective  tissue  of  the  stroma, 
which  takes  part  in  the  process  of  destruction ;  and  finally,  infiltration  and 
gTadual  destruction  of  the  connective  tissue  in  places,  resulting  in  the  formation 
of  cavities  filled  with  pus.  The  suppurative  process  may  involve  the  adipose 
capsule  and  may  be  complicated  with  perinephritis. 

Symptoms. — In  many  cases  of  mild  pyelo-nephritis,  there  may  be  no  sub- 
jective symptoms,  except  a  feeling  of  weakness,  malaise  and  a  dull  pain  or 
heavy  sensation  in  the  loin ;  while  in  more  marked  or  more  advanced  cases, 
the  symptom  complex  is  a  combination  of  the  signs  of  uremia  and  septicemia. 
Some  of  the  symptoms  in  chronic  cases  are  referable  to  the  gastro-intestinal  tract. 
An  acute  attack  usually  sets  in  abruptly  with  chills:  Pain  is  complained  of  in 
many  cases  of  pyelo-nei)hritis  and,  while  usually  of  a  dull  character,  may,  in 
the  presence  of  a  stone  or  undue  mobility,  be  very  severe,  or  associated  with 
colics. 

Colics  also  occur  in  tulierculosis,  but  these  are  of  a  milder  character.  When 
there  are  abscesses,  however,  the  pain  may  be  very  acute  and  the  .muscular 
rigidity  marked.  The  most  marked  pain,  independent  of  colic,  that  I  have 
ever  seen  in  pyelo-nephritis,  was  in  a  case  of  tubercular  kidney  with  abscess 
formation.  The  patients  usually  have  some  elevation  of  temperature.  If  the 
drainage  is  good,  the  temperature  may  be  very  slight — 99°  or  99.5°  P. — but 
when  pus  is  forming  or  has  formed  and  there  is  obstruction  to  its  drainage,  the 
patient  may  have  chills,  a  rise  of  temi)erature  to  105°  or  100°  P.,  sweating 


I 


PYELO-NEPHRITIS  459 

and  syiii])trniis  df  the  mnst  nciitc  s(']")sis.  Tlie  liiiilicsl  tcmpcrat  nrcs  thai  1  lui\'c 
scfU  lia\'('  liccu  ill  (•(iiiiu'ctldii  witli  stricture,  prostatic  hvpcrtropliy  aii<l  tiil)ci'cii- 
losis.  Wlicii  the  abscess  has  broken  into  the  pelvis  and  discharged  tliroiii:h  thtj 
ureter,  as  is  nsually  tlic  case,  the  temperature  falls  again,  and  if  present,  it 
(•(intinnes  in  such  a  mild  degree  that  it  may  not  be  noticed  by  the  patient.  An 
abscess  in  ]\ve](i-nepliritis  may  Ijreak  throngli  the  capsule  ni  tlie  kidney,  gix'iug 
rise  to  a  perinephritic  abscess,  which  we  will  consider  later. 

The  general  symptoms  of  chronic  pyelo-nephritis  may  be  summarized  as 
mihlly  uremic  and  septic,  associated  with  cachexia,  which  gradually  supervenes, 
as  ill  all  slow  su])purative  diseases. 

Examination. — Palpation  generally  shows  a  kidney  which  is  tender  on  pres- 
sure and  enlarged  to  a  varying  degree.  Sometimes  marked  muscular  rigidity  is 
]iresent.  The  temperature  and  \mhe  are  usually  but  slightly  elevated,  except 
when  abscess  formation  or  interference  with  drainage  takes  place,  when  it  be- 
comes so  high  as  to  endanger  the  life  of  the  patient.  In  such  cases,  a  chill  may 
precede  the  rise  of  temperature.  The  fever  is  often  compared  with  malaria, 
and  many  such  patients  enter  the  hospital  with  this  diagTiosis. 

The  nrinary  examination  shows  a  turbid  urine,  yellow,  amber  and  often 
the  color  of  lemonade  or  starch  water,  of  a  specific  gravity  from  1.005  to  1.0^5, 
usually  below  normal.  Sero-albumin  and  nncleo-albumin  are  present;  the  urea 
and  chlorids  are  diminished.  The  microscopical  examination  shows  many  pus 
cells  and  pus  in  masses ;  a  few  red  blood  cells ;  sometimes  crystals ;  epithelia 
from  the  pelvis  and  renal  tubules ;  hyaline,  granular,  epithelial  and  pus  casts. 
Pus  casts  are  pathognomonic  of  a  pus  kidney.  The  finding  of  blood  and  crys- 
tals in  the  urine  points  to  the  presence  of  stone.  The  urine  should  also  be 
examined  for  tubercle  bacilli,  and,  if  negative,  guinea  pigs  should  be  inocu- 
lated. All  patients,  on  whom  the  diagnosis  of  pyelo-nephritis  has  been  made, 
should  be  radiographed  as  a  matter  of  routine,  and  a  diagnosis  can  never  be 
considered  complete  unless  this  examination  has  been  made. 

Having  examined  the  urine  and  having  determined  that  pyelo-nephritis  ex- 
ists, it  is  necessary  to  make  a  thorough  examination  of  the  patient,  as  indicated 
in  the  chapter  on  Examination  of  the  Kidney  and  also  in  the  chapter  on  the 
Examination  of  the  Patient,  to  determine  if  there  is  urethral  stricture,  an  en- 
larged ];rostatc,  any  aluiormality  of  the  bladder  or  ureter.  The  urine  from  each 
kidney  should  be  taken  and  examined  to  discover  if  the  other  kidney  is  healthy 
or  not,  and  its  functional  activity  should  be  determined  in  case  an  operation  is 
considered. 

In  eases  of  i)velo-ne])liritis  in  which  the  predisposing  cause  is  an  impedi- 
ment due  to  stricture  or  prostatic  hypertrojiliy,  the  intlaiiimation  may  lie  the 
same  on  both  sides,  altliough  it  may  vary  in  severity.  In  cases  of  pyelo-nephritis 
due  to  calculus  or  tulierculosis,  either  in  the  ureter  or  kidney,  the  disease  is  much 
more  apt  to  be  unilateral. 


460 


CHKONIC    SUPPUKATIVE    DISEASES    OF    THE    KIDXEY 


PYONEPHROSIS 

Pyonephrosis  is  a  sii])]Turativo  eoiiditioii  of  I  he  kidnc^v  tliat  follows  a  pyelitis 
or  pyelo-nephritis.  It  is  a  pyelitis  with  an  eiilargeiiieiit  of  the  pelvic  cavity, 
plus  suppurative  and  atrophic  changes  in  the  substance  of  the  kidney. 

Etiology. — Pyonephrosis  may  follow  a  pyelitis,  in  which  case  there  is  usu- 
ally some  interference  with  the  emptying  of  the  pelvis,  generally  due  to  a  renal 
calculus  or  to  some  obstruction  or  inflammation  lower  down  in  the  urinary 
tract,  the  ureters,  bladder,  prostate  (Fig.  282)  or  urethra. 


Fig.  282. — Pyonephrosis,   showing   Enlargement  of  the   Kidneys  and   Their  Pelves. 

Observe  the  kinked  ureters. 


Pyonephrosis  may  exist  from  the  first  as  a  pyelitis,  in  which  case  the  jx'h'ic 
cavity  gradually  dilates  and  the  kidney  substance  is  atrophied,  or  it  nuiy  be 
secondary  to  a  m-onephrosis  (hydronephrosis),  which  has  become  infected.  In 
any  case,  as  the  pelvis  increases  in  size,  the  parenchyma  of  the  kidney  is  press(Ml 
upon  and  a  diffuse,  destructive,  chronic  nephritis,  due  to  pressure,  results,  which 
is  associated  with  suppurative  changes  in  the  renal  substance. 

Pyonephrosis  may  also  result  from  a  pyelo-nephritis,  after  part  of  the  paren- 
chyma of  the  organ  has  been  destroyed  by  the  suppurative  process,  owing  to  the 
formation  and  breaking  down  of  the  abscesses.  Among  the  frequent  causes  men- 
tioned in  pyelitis  and  pyelo-nephritis  as  bringing  on  pyonephrosis,  are  stone  and 
tuberculosis.  A  typical  case  of  j^yonephrosis  developing  from  pyelo-nephritis  with 
destruction  of  the  kidney  by  abscesses  may  be  seen  resulting  from  tuberculosis. 


PYONEPHEOSIS 


461 


Pathology. — The  size  of  the  kidney  is  generally  increased  and  its  colcjr  is 
lighter  than  normal.  If  a  vertical  incision  is  made  throngh  the  kidney  and  its 
j)elvis  at  the  convexity,  the  pelvis  will  be  seen  to  he  dilated  to  a  varying  degree, 
with  irregnlar  arches  extending  npward  toward  the  capsnh^,  corresponding  to  the 


Fig.  283. — Cross  Section  of  a  Pygnephrotic  Kidney,  7^2  Inches  Long. 
The  kidney  held  a  pint  of  pus. 

calices,  which  commnnicate  with  the  renal  pelvis  and  with  one  another  (Fig. 
283).  Opening  into  these  arches,  cavities  may  be  seen  that  are  the  results  of 
abscesses.  The  kidney  snbstance  in  more  advanced  cases  is  irregularly  atrophied 
and  in  conjunction  with  the  renal  capsule,  sometimes  resembles  a  shell  divided 
into  large  arches  by  bands  corresponding  to  the  columns  of  Bertini.  There  may 
be  thick  pus ;  or  urine,  detritus  and  pus  mixed — of  a  white  color  in  the  pelvis. 
The  inner  wall  of  the  sac  is  thickened  and  roughened,  and  erosions  may  be  seen. 
The  thickening  is  particularly  marked  in  cases  in  which  a  calculus  has  been  the 
cause  of  the  troul)le.  Tn  tubercular  cases  also  the  walls  are  rough  and  intil- 
trated  in  a  varying  degree.  Areas  of  thickening  are  found  also  in  the  ureters 
in  tuberculosis,  stricturing  them  and  causing  the  obstruction  that  brings  about 
the  pyonephrosis. 

Symptoms. — Pain  is  not  so  marked  as  in  pyelo-nephritis.  It  is  of  variable 
severity  and  sometimes  altogether  absent.  The  ]-)ain  is  generally  most  acute 
in  cases  of  renal  calculus  or  movable  kidney,  in  which  the  ureter  becomes  blocked 


462  CTIRONrC    SUPPURATIVE   DISEASES    OF   THE    KIDXEV 

or  kinked  and  the  organ  is  suddenly  distended  with  pns  and  nrine.  It  may  also 
radiate  down  the  ureter  in  stone  eases.  The  patient  has  considerable  distress 
and  often  nausea  and  vomiting  when  the  kidney  is  distended.  There  is  marked 
pyuria  when  the  organ  is  draining  well,  and  slight  or  no  fever ;  bnt  when  the 
drainage  is  blocked,  there  may  be  a  chill  and  a  rise  of  temperature  to  10.3'^  or 
104°  F.  which  drops  as  soon  as  the  drainage  is  reestablished.  It  is  most  com- 
mon in  calculous  cases. 

Examination. — Examination  usually  shows  a  large  kidney,  palpal)le  to  a 
varying  degree  and  best  detected  by  ballottement.  This  is  especially  the  case 
when  the  pelvis  is  distended  with  pus.  Large  pyonephrotic  kidne_ys  often  can- 
not be  outlined,  however,  as  their  walls  collapse  when  pressure  is  made.  Ten- 
derness is  not  as  common  as  in  pyelo-nephritis,  but  it  is  present  when  the  sac  is 
very  much  distended. 

The  urine  is  lighter  in  color  than  in  pyelo-nephritis,  often  having  a  milky, 
starchy,  or  lemonade  color.  It  is  of  lower  specific  gTavity,  and  contains  albumin, 
a  diminished  amount  of  urea  and  chlorids,  granular,  epithelial,  pus  and  mixed 
casts,  pelvic  and  renal  epithelia,  a  few  red  blood  cells,  many  pus  cells  and  pus  in 
masses.  In  tubercular  cases,  the  bacilli  are  found,  and  in  cases  due  to  calculus, 
crystals  may  be  found. 

The  urine  varies  in  amount  and  appearance  when  the  disease  is  on  one 
side  and  due  to  stone.  It  is  turbid  when  secreted  from  both  kidneys,  but  may 
be  clear  and  scant  when  coming  from  a  healthy  kidney  during  an  attack  of 
retention  in  the  pelvis  of  the  diseased  organ. 

Pyonephrosis  is  a  more  chronic  process  than  is  pyelo-nephritis.  It  sometimes 
happens  that  we  have  an  acute  pyelo-nephritis  on  one  side  and  a  chronic  ]iyo- 
nephrosis  on  the  other.  In  this  case,  there  may  be  no  pain  on  the  side  of  the 
pyonephrosis,  even  when  the  organ  is  nearly  destroyed.  On  the  side  of  the 
acute  pyelo-nephritis,  there  may  be  a'  large  amount  of  functionating  renal  tis- 
sue, and  nearly  all  the  elimination  may  take  place  from  that  organ ;  and  yet 
muscular  rigidity,  pain  and  tenderness  are  present  and  all  subjective  symptoms 
j>oint  to  it  as  the  principally  affected  kidney.  Catheterization  of  the  ureters 
shows  the  difference  between  the  two  organs,  as  the  urine  coming  from  the  ])yo- 
nephrotic  side  on  which  there  are  no  symptoms  would  show  a  considerable 
amount  of  thin  fluid  resembling  pus  and  water  mixed,  containing  but  a  small 
amount  of  solids ;  whereas,  on  the  side  on  which  the  acute  symptoms  are  present, 
the  urine  might  be  comparatively  normal  in  color  and  would  contain  a  greater 
amount  of  solids,  as  well  as  the  products  of  inflammation. 

Diagnosis. — The  diagnosis  of  pyonephrosis  depends  on  finding  a  urine  hav- 
ing the  turbid  or  starch-water  appearance,  and  finding  that  it  contains  albumin, 
pus,  renal  epithelia  and  various  kinds  of  casts,  including  pus  casts.  Then,  on 
catheterizing  the  ureters,  it  will  be  seen  that  the  elements  of  kidney  disease 
found  in  the  general  urine  can  be  accounted  for  by  the  urine  coming  from  the 


TREATMENT  403 

suspected  kidney.  A  considerable  amount  of  ui-ine  from  the  diseased  kidney 
may  run  out  as  soon  as  the  catheter  is  introduced  into  its  pelvis,  perhaps  half 
an  ounce  or  more,  which,  on  examination,  will  be  found  to  consist  principally 
of  a  clear  fluid  with  but  a  small  amount  of  solids,  albumin,  considerable  pus  and 
other  pathological  kidney  elements. 

In  both  pyelitis  and  pyelo-nephritis,  the  urine  is  generally  of  a  higher 
specific  gravity  than  in  pyonephrosis  and  would  contain  more  solids.  Pviii-ia 
is  more  marked  in  pyonephrosis  than  in  either  pyelitis  or  pyelo-nephriiis. 

The  diagnosis  of  the  cause  of  the  p3^onephrosis  is  more  difficult  and  includes 
all  the  various  steps  that  have  been  included  in  the  chapter  on  Examination  of 
the  Kidney. 

Treatment  of  Pyelitis,  Pyelo-nephritis  and  Pyonephrosis 

In  case  of  pyelitis,  as  soon  as  the  diagnosis  has  been  made  and  even  before 
the  cause  has  been  determined,  it  is  advisable  to  have  the  patient  drink  a  con- 
siderable amount  of  water,  say  two  quarts  a  day,  to  flush  the  kidneys,  and  to  give 
three  times  a  day  an  internal  urinary  antiseptic,  such  as  urotropin,  10  grains; 
benzoate  of  soda,  15  grains;  benzoic  acid,  15  grains;  salol,  5  gTains,  or  other 
urinary  antiseptics.  Lavage  and  injections  of  the  renal  pelvis  by  means  of 
ureteral  catheters  have  been,  practiced  for  many  years  and  have  been  advo- 
cated especially  in  cases  of  gonorrheal  pyelitis,  which  condition  has  been  ex- 
tremely rare  in  my  practice.  For  several  years,  lavage  and  injections  of  the 
pelvis  through  the  ureteral  catheters  have  been  employed  quite  extensively  by  us 
in  the  cystoscopic  room  of  the  clinic,  and  several  thousand  lavages  and  injec- 
tions have  been  made.  Most  of  these  cases  had  but  slight  symptoms  and  dis- 
continued their  visits  on  account  of  the  inconvenience  the  treatment  occasioned 
them.  In  one  case  of  gonorrheal  pyelitis,  due  to  gonorrheal  infection,  the  pelvic 
lavage  and  injections  with  solution  of  nitrate  of  silver  and  its  derivatives  were 
kept  up  constantly  for  two  years,  but  the  gonococci  Avere  still  present  at  the 
last  examination  and  the  jDatient  was  no  better ;  if  anything,  he  was  worse.  So 
far,  covering  a  period  of  nine  years  that  cases  of  pyelitis  have  been  treated  by 
lavage  of  the  renal  pelvis,  there  is  not  a  history  of  a  single  case  that  has  been 
cured  by  this  method.  The  solutions  nsed  were  a  silver  nitrate,  1 :  4,000  to 
1 :  2,000  or  milder,  alone  or  combined  with  boracic  acid  ;  protargol,  one  half  to 
two  per  cent  in  strength ;  argyrol,  ten-  to  twenty-five-per-cent  solution ;  and 
1 :  5,000  solution  of  formalin.  But  few  patients  seem  to  have  been  relieved  by 
such  treatment.  Some  of  these  patients  have  had  injections  of  the  renal  pelvis 
more  than  a  hundred  times  and  did  not  improve.  Injections  of  silver  solution 
and  protargol  seem  to  have  been  the  most  eft'ective,  and  doubtless  nuiny  who  have 
been  treated  at  the  clinic  recovered  later. 

Pyelitis  without  a  predisposing  cause  is  an  cxtvomely  rare  condition,  if 
it  ever  exists,  and  patients  suffering  from  it  should  never  be  subjected  to  such 


464  CHROXTO    SFPrFKATTVE    DISEASES    OF    THE    KTDXEV 

local  troatineiit  until  tlic  ])li_vsician  lias  discox-crcd  ilic  f-auso  and  ro^isidL'V.s 
pelvic  injections  indicated.  Otlierwisc,  he  niii:lil  inject  the  ])e]vis  of  a  tuliei-- 
cnlar  kidney,  in  wliicli  case  tlie  jjassinii'  of  a  catlieter  niiiilit  aii'O'ravate  the  con- 
dition and  also  ])i'o\'oke  tnhei'cnlar  lesions  in  the  nretei*  throngli  catheter 
tranniatisni. 

Tlie  sni'oical  treatment  of  cln-oii'ic  j,j/rjilis  consists  in  the  removal  of  the 
canse.  Sometimes,  in  ])yelitis  dnc  to  ol)strnction  wliicli  may  exist  anywhei-e 
from  the  cavity  of  the  pelvis  itself  to  the  external  nrethral  meatns,  it  may  1)0 
easy  to  locate  the  canse.  These  obstrnetions  are  nsnally  nrethral  strictnre, 
prostatic  hypertrophy,  vesical  tnmor,  stone  in  the  nreter,  or  pressnre  hy  oi-n^vths 
or  adhesions  ontside  of  the  nreter ;  or  stone  or  growth  in  the  jDclvis  of  the  kidney. 
In  snch  cases,  the  obstrnction  shonkl  be  overcome  as  follows:  Urethral  strictnres 
shonkl  be  dilated  or  cnt ;  hy])ertrophic  prostates  shonld  be  subjected  to  catheter 
life  or  prostatectomy;  vesical  calcnli  shonld  be  crushed  or  removed  by  supra- 
pubic cystotomy ;  vesical  tumors  should  be  excised  through  a  suprapubic  in- 
cision or  fulgurated ;  stone  in  the  ureter  should  be  removed  by  ureterotomy ;, 
ureteral  stricture  should  be  dilated  or  ureterorrhaphy  or  plastic  operations  per- 
formed ;  adhesions  about  the  ureter  should  be  broken  up  and  the  canal  stretched 
out;,  growths  pressing  upon  the  ureter  should  be  removed;  a  renal  calculus 
should  be  removed  by  nephrolithotomy;  obstruction  in  the  pelvic  wall  should 
be  treated  by  plastic  operations ;  while  in  cases  of  tumor  of  the  pelvis,  the  entire 
organ  should  be  removed  (nephrectomy),  (See  chapters  on  Operative  Surgery 
of  the  Renal  Pelvis  and  Ureter.) 

The  treatment  of  pyeJo-neplintis  is  either  palliative,  expectant,  or  radical, 
depending  upon  the  symptoms.  In  case  a  patient  has  a  chill,  followed  by  a  fever, 
and  examination  shows  tenderness  and  perhaps  a  noticeable  enlargement  of  one 
kidney,  it  does  not  necessarily  mean  that  this  kidney  will  develop  an  abscess  that 
will  require  immediate  operation,  for  the  symptoms  often  subside  with  rest  in 
bed,  milk  diet,  diuresis  and  urotropin.  It  is  also  advisable  to  cup  the  patient 
over  the  kidney,  to  keep  the  bowels  open  and  to  give  quinin,  three  gTains,  three 
times  a  day.  If  the  temperature  continues  high  and  assumes  a  septic  curve,  a 
nephrotomy  should  be  performed  and  the  kidney  drained,  although  probably,  if 
no  operation  were  performed,  the  abscess  would  rupture  into  the  renal  pelvis. 
If  the  nephrotomy  shows  the  kidney  to  be  extensively  diseased  and  a  condition 
of  chronic  sepsis  which  is  injuring  the  patient's  health  continues  after  the  opera- 
tion, a  secondary  nephrectomy  should  be  performed,  provided  the  other  kidney 
is  sufficiently  healthy  to  carry  on  the  renal  function.  A  tubercular  kidney  in 
a  state  of  pyelo-nephritis  shonld  always  be  removed  in  case  the  other  kidney  is 
capable  of  carrying  on  the  work.  In  calculus  pyelo-nephritis,  nephrolithotomy 
should  be  performed,  nephrectomy  being  reserved  for  those  cases  in  which  the 
renal  tissue  is  almost  entirely  destroyed. 

A  pyelo-nephritis  of  any  variety  may  break  down  and  empty  into  the  pelvis 


TREATMENT  4G5 

inilil  tlio  l<i(lii('_v  tissue  is  extensively  destroyed,  eaiisiuc;  an  extensive  rrmo- 
])elvie  cavity,  pyonephrosis;  or  an  abscess  may  l)reak  llii-oiiuh  liie  capsnla 
jiropria,  giving  rise  to  a  perinepliritic  abscess. 

Cases  of  j)yelo-nephritis  not  dne  to  obstruction,  tumor,  or  calculus,  sometimes, 
under  favorable  conditions,  undergo  a  change  for  the  better  in  any  stage  of  the 
disease,  the  involved  areas  break  down  and  are  cast  off  in  the  urine,  or  else  they 
develop  into  fibrous  tissue.  This  occurs  in  tubercular  cases  oftener  than  is  gen- 
erally supposed.  In  cases  due  to  obstruction  and  stone,  however,  the  obstacles 
must  be  removed  before  the  destructive  process  in  the  kidney  is  arrested. 

In  the  treatment  of  pyonephrosis,  it  may  be  said  that  a  pyonephrotic  kidney 
can  always  be  removed  if  the  other  kidney  is  able  to  keep  up  the  work  of  elim- 
ination necessary,  and  it  is  recommended,  if  the  kidney  tissue  is  very  much 
destroyed.  In  cases  of  nephrolithiasis  and  pyonephrosis,  I  prefer  to  remove  the 
stone  by  nephrotomy  and  drain  the  kidney  with  the  object  of  seeing  if  the  fis- 
tula, which  usually  follows,  will  close,  and  if  some  functionating  renal  tissue 
will  remain;  and  then  in  case  the  kidney  is  found  later  to  have  no  power  of 
elimination,  to  perform  a  secondary  neiDhrectomy.  Pyonephrotic  kidneys  occur 
in  renal  tuberculosis  as  well  as  do  pyelo-nephritic  and  should  be  removed  if  the 
other  kidney  is  sufficiently  healthy.  Pyonephrotic  kidneys  due  to  any  trouble 
may  be  entirely  destroyed  and  remain  as  atrophic,  nonfunctionating  shells,  or 
masses  of  fibrous  tissue.  Calculous  pyonephrosis  may  act  in  the  same  way  after 
removal  of  the  stone  by  nephrotomy.  A  pyonephrotic  kidney  may  undergo 
rupture,  giving  rise  to  a  perinepliritic  abscess.  In  one  case  of  perinepliritic 
abscess,  I  found  a  renal  calculus  lying  outside  the  kidney,  which  was  but  a  mass 
of  fibrous  tissue  surrounded  by  suppuration. 

When  the  patient  is  in  such  poor  general  condition  that  any  operation  is  con- 
traindicated,  the  treatment  must  be  expectant  or  palliative  and  it  is  then  the 
same  as  the  conservative  treatment  of  pyelitis  and  pyelo-nephritis. 

Personally,  I  am  inclined  to  believe  that  the  literature  of  suppurative  dis- 
eases of  the  kidney  is  still  governed  by  that  of  the  past  and  will  be  greatly 
changed  in  the  next  few  years.  I  think  that  formerly  many  cases  of  pyelo- 
nephritis and  pyonephrosis  were  called  pyelitis ;  also  that  many  cases  of  pyelitis 
with  but  few  symptoms  of  pain,  or  else  pain  of  a  dull  character,  Avere  due  to 
stone.  Many  other  cases  Avere  probably  due  to  tuberculosis,  in  which  not  much 
renal  enlargement  was  found  and  the  tubercle  bacilli  were  not  discovered.  As 
the  date  of  the  literature  of  pyelitis  dates  back  much  farther  than  that  of  such 
up-to-date  methods  of  renal  diagnosis,  as  radiography  in  renal  calculus  and  the 
detection  of  the  tubercle  bacilli  by  the  microscope  and  by  the  injection  of  guinea 
pigs,  it  is  easy  to  see  how  many  cases  of  these  suppurative  diseases  of  the  type 
mentioned  in  the  literature  might  have  been  due  to  these  causes.  Again  with 
the  thorough  training  in  surgery  that  the  students  of  the  medical  schools  now 
have,  the  obstructive  lesions  of  the  urinary  tract,  which  are  the  principal  causes 


466  CHEONIC    SUPPURATIVE   DISEASES    OF   THE   KIDNEY 

of  these  troubles,  will  be  better  understood  and  attended  to  before  the  renal  sup- 
puration has  taken  place. 

More  study  of  these  diseases  should  be  made  by  those  interested  in  renal 
surgery  to  make  this  involved  subject  more  comprehensive  to  the  practitioner. 

PERINEPHRITIC   ABSCESS 

A  perinephritic  abscess  is  a  collection  of  pus  about  the  kidney,  usually  situ- 
ated between  that  organ  and  the  posterior  abdominal  wall.  It  is  unilateral 
in  about  ninety-nine  per  cent  of  the  cases  and  is  more  common  on  the  right 
side. 

Etiology. — Generally,  cases  are  called  primary  which  originate  in  the  peri- 
nephritic tissues  per  se,  and  secondary  when  due  to  the  extension  of  infection 
from  the  kidneys  or  other  organs  or  tissues.  Primary  abscess  has  been  at- 
tributed to  traumatism,  blows,  exertion  and  congestion  from  heat  or  cold.  Per- 
sonally, I  do  not  believe  that  any  one  of  these  primary  causes  is  sufficient  to 
produce  a  perinephritic  abscess,  except  when  the  traumatism  opens  the  peri- 
nephritic tissue  and  carries  in  infection,  as  in  the  case  of  a  stab  or  gunshot 
wound.  I  believe,  however,  that  the  blow^s  and  exertion  are  the  active  cause 
of  the  trouble  when  a  suppurative  focus  is  present  in  the  kidney  or  some  other 
organ  or  tissue,  I  think  that  a  better  classification  would  be,  'primary,  wdien 
due  to  a  suppurative  process  in  the  kidney,  and  secondary,  when  due  to  a  sup- 
purative process  elsewhere. 

I  further  believe  that  seventy-five  per  cent  of  the  cases  originate  in  the  kid- 
ney. In  an  address  that  I  delivered  before  the  Chicago  Medical  Association  in 
1905,  I  stated  that  I  believed  that  nearly  all  cases  were  due  to  renal  disease  and 
that  those  secondary  to  disease  of  other  organs  are  rare  and  not,  properly  speak- 
ing, perinephritic  abscesses.  These  deductions  w^ere  based  on  a  study  of  fifteen 
consecutive  cases,  in  which  renal  suppuration  existed  in  fourteen.  I  will  here 
quote  the  statistics  of  the  cases : — 

Penal  calculus   4 

Renal  tuberculosis   -i 

Pyonephrosis 3 

Pyelo-nephritis 2 

Rupture  of  kidney 1 

Empyema 1 

Since  then,  I  have  had  five  more  cases  that  I  can  recall,  three  of  which  Avere 
due  to  tuberculosis,  one  to  necrosis  of  the  rib  and  the  other  one  I  could  not 
account  for.  This  would  change  the  statistics  in  my  last  twenty  consecutive 
cases,  which  I  will  consider  under  the  names  of  the  diseases : — 


PERINEPHRITTC    ABSCESS  467 

r  ( 'ak'uloiis    3 

Pyonephrosis  <^   Tubercnlous    5 

[  Obstructive 3 

Total 11 


Pyelo-nephritis  < 
Total   . .  . 


''  Calculous 1 

Tuberculous    2 

Obstructive 2 


Rupture  of  kidney 1 

Empyema 1 

Necrosis  of  rib 1 

Unknown   cause,    probably    suppurative    retroperito- 
neal gland 1 

Total 4 

Full  total   20 

This  makes  the  statistics  eighty-five  per  cent  due  to  renal  trouble,  which 
differs  from  the  statistics  of  former  writers  and  depends  on  a  careful  analysis  of 
catheterized  specimens  of  urine  taken  from  each  kidney,  as  well  as  an  inspection 
of  the  kidney  at  the  time  of  the  first  operation  or  shortly  afterwards. 

Cases  of  secondary  perinephritic  abscess  result  from  the  extension  of  a  sup- 
purative process  from  other  organs  or  tissues,  either  in  the  abdominal,  pelvic  or 
the  thoracic  cavity.  When  secondary  to  disease  of  an  organ  in  the  abdomino- 
pelvic  cavity,  if  the  organ  at  the  site  of  the  suppuration  is  not  covered  by  peri- 
toneum, the  pus  can  extend  or  burrow  beneath  or  behind  the  peritoneum  until 
it  reaches  the  perirenal  tissues.  If  the  organ  at  the  site  of  the  suppuration  is 
covered  by  peritoneum,  the  apposing  surfaces  of  visceral  and  parietal  peritoneum 
must  first  adhere  before  the  suppurative  process  can  pierce  the  two  layers  and 
reach  the  perirenal  fossa. 

Among  the  conditions  in  the  abdomino-pelvic  cavity  wdiich  may  give  rise 
to  perinephritic  abscess,  the  following  may  be  mentioned :  Abscess  of  the  liver, 
suppurative  cholecystitis,  abscess  of  the  spleen  or  pancreas,  typhoid  fever,  ap- 
pendicitis, ulcerative  colitis,  operations  or  diseases  of  the  rectum,  impaction  of 
feces  with  ulceration,  prostatic  abscess,  diseases  or  injuries  of  or  operations  on 
the  urethra,  the  spermatic  cord  or  the  testes,  diseases  of  or  operations  on  the 
uterus  and  adnexa.  Next  follow  the  conditions  in  the  thoracic  cavity  that  may 
give  rise  to  perinephritic  abscess,  Avhich  are  abscess  of  the  lungs  and  empyema. 
In  these  cases,  the  suppurative  process  extends  through  the  pleura  and  dia- 
phragm into  the  perirenal  space.  The  disease  is  more  common  than  is  generally 
supposed. 


468 


CHIIOXIC    SUPPURATIVE    DISEASES    OE    THE    KIDXEi' 


Symptoms  and  Diagnosis. — The  diagnosis  of  perinepliritic  abscess  p<??-  sc 
is  not  usually  diiiicult ;  but  the  tliscovery  of  the  sources  is  often  not  only  ditH- 
cult  but  impossible,  'i'he  onset  of  the  trouble  is  the  same  as  that  of  any  other 
deep-seated  abscess:  sejjtic  fever,  sweatinii',  perhaps,  ushered  in  Avith  a  chill  or 
chilly  sensation.  The  grade  of  fever  varies  in  different  cases,  depend iug  upon 
the  amount  of  leakage  into  the  perirenal  sj'iace  and  the  character  of  the  infec- 
tion. The  other  general  symptoms  are  loss  of  appetite,  strength  and  weight, 
headache,  coated  tongue,  nausea,  flatulence  and  constipation.  The  local  symp- 
toms begin  with  a  feeling  of  fullness,  or  a  dull  deep-seated  pain  in  the  space 
under  the  twelfth  rib,  which  becomes  worse  on  deep  inspiration.  Pain  in  any 
other  region  than  the  loin  in  such  cases  may  mean  a  referred  pain,  or  that  the 
abscess  has  burrowed  away  from  the  loin  behind  the  jDcritoneum  to  other  parts, 
or  that  the  region  in  which  the  pain  is  most  marked  is  the  source  of  the  abscess. 
The  pain  may  at  times  be  paroxj'smal  in  character  and  may  be  attributed  to 
various  directions  as  the  hypogastrium,  groin,  testis  or  even  to  the  knee,  owing 
to  the  wide  distribution  of  the  lumbar  plexus.  This  occurs  principally  in  cases 
that  are  due  to  renal  calculus. 

Examination. — The  temperature  may  run  from  99°  to  100°  F.  or  from 
103°  to  105°  F.,  the  usual  grade  being  from  99°  to  102°  F.  The  pulse  in  peri- 
nephritic  abscess  is  often  rapid  at  first,  full  and  hard,  while  later  it  Avill  be 
found  to  be  small,  rapid  and  weak,  as  the  sepsis  increases.     The  skin  is  usually 

hot    and     dry,     or    covered 
with  profuse  perspiration. 

The  position  of  the  pa- 
tient is  often  quite  charac- 
teristic. When  he  lies  on 
his  back,  the  thigh  on  that 
side  will  not  extend  beyond 
the  angle  of  1G0°  to  180°. 
In  walking,  he  shows  more 
or  less  stiffness  and  inclines 
the  body  to  the  affected  side. 
Some  cases,  however,  fail  to 
show  any  of  these  signs. 

There  is  tenderness  on 
pressure  in  the  loin,  as  well 
as  in  the  abdomen.  In 
some  cases,  there  is  a  tumor  or  swelling  noted  on  one  side  on  inspection,  the 
lumbar  hollow  being  replaced  by  a  slight  bulge  of  the  tissues  under  the  ribs. 
This  difference  is  chiefly  noted  when  the  patient  is  sitting  or  standing  and  may 
be  overlooked  when  he  is  recumbent.  Gradually  the  ileo-costal  curve  is  obliter- 
ated, as  in  Figs.  284  and  285.     The  lumbar  tumor  often  does  not  appear  until 


Fig.  284. 


-Bulge  in  Perinephritic  Abscess  in  Lei't  Side 
OF  Loin.     Front  view.     (Author's  case.) 


PERINEPHRITTC    ABSCESS 


469 


^vcc'k.s  after  llio  onset  (if  the  sii])])iii'ati()ii.  Siicli  a  slow  proeoss  is  nsnally  asso- 
ciated Avith  a  case  of  tiihereular  kidney  in  which  the  capsula  propria  and  the 
external  capsule  have  be- 
come adherent,  and  the  ab- 
scess is  walled  off  as  it  ex- 
tends. The  sudden  rupture 
of  a  larue  abscess  of  the 
kidney  into  the  perirenal 
space,  in  a  case  in  which 
tliere  has  l)cen  no  or  but  a 
slight  Avalling-off  process, 
often  residts  in  a  very  acute 
onset  and  a  rapid  develop- 
ment of  pus  and  tumor. 

On  palpation  a  diffuse 
tumor  is  felt  principally  in 
the  back  part,  which  does 
not  have  the  outline  of  a 
kidney  and  cannot  be  bal- 
lotted. 

There  is  sometimes  dull- 
ness on  percussion,  espe- 
cially if  the  abscess  is  su- 
perficial. On  the  right  side, 
the  dullness  is  continuous 
with  that  of  the  liver  be- 
hind, while  on  the  left,  it 
is  continuous  with  that  of 
the  spleen.  Fluctuation  is 
sometimes  present  early  in 
the  course  of  the  disease ; 
more  often  it  appears 
later,  but  usually  not  at  all. 
Redness  of  the  surface  is 
rarely  noticed,  as  the  ab- 
scess is  below  the  deep  fascias.  I  have  had  one  case  in  which  three  quarts 
of  pus  were  present  and  yet  there  were  neither  redness  nor  fluctuation. 

The  last  steps  of  the  diagnosis  depend  on  a  puncture  or  an  incision. 

Diagnosis  for  the  Source  of  the  Abscess. — Having  made  a  diagnosis  of  peri- 
nephritic  abscess,  an  attempt  should  be  made  in  every  case  to  discover  the  source 
of  the  suppuration.  In  the  first  place  a  careful  history  should  be  taken  to  find 
out  from  what  diseases  the  patient  has  suffered  recently,  whether  he  or  she  has 


Fig.  285. — Characteristic  Bul(;e  ix  a  Perinephritic  Ab- 
scess ON  THE  Left  Side.     Bactc  view.     (Author's  case.) 


470 


CHKONIC    SUPPURATIVE    DISEASES    OF    THE    KIDXEY 


had  aiiv  injury  of  the  abiluiiiiiinl  or  llKti-at-ic  (•a\'it_v,  or  wlietlicr  an  operation  lias 
been  performed  in  these  regions.  If  such  is  found  to  he  tlie  ease,  the  point  of 
tlie  inflammation,  injury  or  operation  is  the  one  which  sh<»ul(l  l)e  looked  to  as 
the  source  of  the  abscess. 

If  there  is  no  such  history,  a  systematic  examiiuition  slioidd  lie  resoi-ted  lo. 
The  urine  should  be  carefully  examined  for  evi<lenee  of  kidney  disease.     If  ])us 

is    found    in    the    urine,    we    sliould 
endeavor     to     determine     whether     it 
comes   from    the   kidney,    and    if   so, 
we     should     determine     by     ureteral 
catheterization     whether      it      comes 
from  the  kidney  of  the  affected  side. 
It    must    be    remendjered,     however, 
that  a   ])erine})liritie   aljscess   may   he 
secondary   to   an  abscess  of  the   kid- 
ney, even  if  no  })us  is  found  in  the 
urine,    as    in    Yiix.    -■'^G,    which    re- 
sulted .  from     a     tr.bercular     cortical 
abscess.     It    did    not    commu- 
nicate with   the   pelvis.      Gen- 
erally,    howe\'er,     there     is     a 
suppurative  process  connected 
with    the    kidney    pelvis,    and 
j)us  Avill  be  found  in  the  urine 
Wi    (Figs.  287  and  :>8S). 

If  we  cannot  satisfy  our- 
selves that  the  source  of  the  troul)le 
is  in  the  kidney,  we  should  make  a 
thorough  and  systenuitic  examina- 
tion of  the  organs  in  the  abcb^ni no- 
pelvic  and  thoracic  cavities.  In  mak- 
ing this  examination,  we  should  have 
in  mind  the  various  conditions  that 
may  give  rise  to  perinephritic  ab- 
scess, mentioned  under  Causes. 
It  must  be  remembered  that,  when  we  find  a  perinephritic  abscess  that  has 
existed  for  some  time,  and  there  is  pus  in  some  other  neighboring  localities,  it 
is  difficult  to  say  whether  the  pus  came  from  the  other  point  and  settled  in  the 
perirenal  space,  or  extended  from  the  perirenal  space  to  these  localities,  or 
simply  accumulated  in  this  space  as  a  depot  while  traveling  from  one  point  to 
another. 

It  should  also  be  borne  in  mind  that,  after  opening  the  abscess  and  washing 


Fig.  286. — Posterior  Surface  of  Left  Kidney 
IN  A  Case  of  Perinephritic  Abscess.  Shows 
opening  of  a  cortical  tubercular  abscess  which 
communicated  with  the  perinephritic  cellular 
tissues.     (Author's  case.) 


PERINEPHRITIC    ABSCESS 


471 


it  out,  the  finger  should  palpate  carefully  the  entire  region  for  openings,  how- 
ever small,  in  the  surface  of  the  kidney  or  adjacent  structures,  or  for  sinuses 
running  up  to  more  distant  tissues.  All  such  openings  should  be  probed  and 
examined  with  an  electric  light  thrown  into  the  cavity.     In  the  case  of  the 


Fig.  287. — Posterior  Surface  of  Tuberculous 
Kidney  in  a  Case  of  Perinephritic  Abscess. 
The  organ  was  4  inches  long.  Note  the  open- 
ing on  its  surface.     (Author's  case.) 


Fig.  288. — Longitudinal  Section  of  Same  Kid- 
ney, SHOWING  Contracted  Pelvis  now  not 
Much  Larger  Than  the  Ureter.  The  renal 
fistula  extends  from  the  pehds  to  the  point  where 
it  has  broken  through  the  capsule  of  the  kidney 
as  a  perinephritic  abscess.     (Author's  case.) 


tubercular  cortical  abscess,  just  referred  to,  the  tip  of  the  finger  could  just  be 
inserted  into  the  abscess  cavity  in  the  kidney.  There  was  no  ]nis  in  the  urine. 
The  patient  developed  shortly  after  this  a  tuberculous  knee,  requiring  ex- 
cision, and  thus  confirming  the  clinical  diagnosis  of  a  preceding  tuberculous 
abscess. 

The  Course  of  the  Abscess. — The  course  of  the  abscess  varies.  In  the  first 
])lacc,  it  may  be  absorbed  after  being  walled  off  by  connective  tissue.  I  have 
had  one  such  case  in  which  all  the  symptoms  gradually  subsided.  Again,  it 
may  extend  through  Petit's  triangle  and  ru])ture  externally.  Very  few 
abscesses  rupture  externally  or  into  the  intestinal  or  urinary  tract ;  but  the 
patients  die  of  a  slow  sepsis  unless  operated  upon.  The  abscess  may  break  into 
the  pleural  cavity  or  lungs,  in  which  latter  case  it  is  coughed  up  and  the  pa- 
tient may  recover,  although  usually  he  dies  of  sepsis  unless  the  pleural  cavity 
and  the  perinephritic  space  are  both  opened.  Rupture  into  the  peritoneal  cav- 
ity is  followed  by  septic  peritonitis  and  death. 


472  CHRONIC    SUPPURATIVE    DISEASES    OF    THE    KIDNEY 


When  the  abscess  burrows  aloiii!;  the  psoas,  it  gives  the  symptoms  of  psoas 
abscess.     The  tumor  is  felt  as  a  fluctuatiiig  mass  at  or  below  Poupart's  ligament, 

and  may  extend  down  the 
thigh.  Fig.  280  shows  the 
point  of  bulging  of  a  peri- 
nephritic  abscess  just  above 
Pou part's  ligament  and  the 
point  (.4.)  at  which  it  was 
opened  in  the  inner  side  of 
the  tliigh.  It  may  extend 
to  the  pelvis  and  break 
into  the  gut  or  urinary 
tract,  or  through  the  saero- 
sciatic  foramen  into  the  sci- 
atic region,  beneath  the  glu- 
teal muscles  or  on  the  back 
of  the  thigh.  When  peri- 
nephritic  abscesses  break 
externally,  it  is  usually  in 
the  loin ;  next  in  frequency, 
the  pleura  and  bronchi ;  and 
after  this,  the  intestine. 
Treatment  of  Perinephritic  Abscess. — As  soon  as  the  diagnosis  of  peri- 
nephritic  abscess  is  ascertained,  a  lumbar  incision  should,  be  made  into  the 
perirenal  space  to  allow  the  escape  of  pus,  after  which  the  cavity  is  washed  out 
with  salt  solution  and  then  with  peroxid  and  again  with  salt  solution.  The 
abscess  cavity  should  then  be  explored  with  the  finger.  It  is  often  surprising 
to  note  how  extensive  such  a  cavity  may  be,  the  fingers  going  up  to  the  dia- 
phragTn  and  down  into  the  iliac  fossa,  or  even  into  the  pelvis.  In  cases  in  which 
a  pyonephrotic  kidney  has  ruptured,  the  fingers  may  find  themselves  in  the 
pelvis  of  the  kidney.  It  is  very  difficult  for  anyone,  who  has  not  an  experi- 
enced touch,  to  open  a  lumbar  abscess  and  ascertain  the  exact  source  of  the  pus. 
For  this  reason,  the  kidney  should  always  be  palpated  carefully  to  see  if  there 
is  an  opening  into  it,  or  if  the  organ  feels  pathological.  If  an  opening  is  found, 
the  finger  should  be  inserted,  and  in  case  it  enters  the  pelvis,  the  cavity  should 
be  palpated  to  discover  if  calculi  are  present.  In  that  case,  they  should  be 
removed.  If  there  is  an  opening  in  the  kidney  that  will  not  admit  the  finger, 
a  cigarette  drain  should  be  inserted  down  to  it  and  the  incision  closed,  with  the 
idea  of  opening  it  again  in  a  few  days,  when  the  patient  is  better  able  to  stand 
the  operation,  or  when  the  tissues  have  again  resumed  their  normal  relations. 
In  some  cases,  the  kidney  is  so  pushed  to  one  side  that  it  cannot  be  located  at 
the  time  of  the  first  operation  and  it  will  be  necessary  to  explore  it  later. 


Fig.  289. — A  Bulging  of  Pus  in  the  Groin  and  an  Opening 
IN  THE  Thigh  Made  to  Drain  a  Perinephritic  Abscess 
THAT  Had  Burrowed  Down  from  the  Renal  Fossa. 
(Author's  case.) 


ABSCESS    OF    THE    KIDNEY 


473 


Duriiiii'  tlifsc  sccdiidiirv,  cxploralory  ()])('i';i1  ions,  tlic  kidney  can  Ix'  more 
carL'tully  examined  and  an  exjiloi'atory  or  drainage  neplii-olomy  perfoi'med,  or 
a  nephrectomy,  as  decided  upon  by  existing  conditions.  In  four  cases  in  which 
a  i)erinephritic  abscess  was  dne  to  a  calcnlns,  in  one  ease  the  calcnhis  had  been 
discharged  from  the  kidney  with  the  pns  wlien  it  ruptured.  (See  chapter  on 
Ivenal  Calculus.)  In  an- 
other case,  the  stone  was  felt 
]U'otruding  from  the  kid- 
ney like  a  spur  and  was 
pulled  out  (Fig.  290).  In 
still  another,  there  was  a 
small  sinus  in  the  kidney 
and  tlie  stone  was  not  dis- 
covered until  an  explora- 
tory nephrotomy  had  been 
performed.  In  another  in- 
stance, I  could  not  find 
the  stone  at  nephrotomy 
and  it  was  not  until  later 
after  a  nephrectomy  had 
been  performed  that  the  cal- 
culus was  discovered  in  a 
pocket.  In  all  my  opera- 
tions on  tuberculous  kid- 
neys, with  one  exception, 
the  opening  into  the  kidney 
communicated  directly  with 
the  pelvis. 

In  the  case  in  which  the 
abscess  burrowed   down  be- 
neath Poupart's  ligament,  it 
was  opened  in  the  inner  part        ^^^-  290. — A    .Sharp-pointed    Calculus   that  Was   Found 
■     „    ,        1  •    T     /  T-i-  \  Sticking  through  the  Wall  of  the  Kidney  in  a  Case 

of  the  thigh   (see  ilg.   289).  of  Perinephritis.     (Author's  case.) 


ABSCESS    OF   THE   KIDNEY 

There  are  several  forms  of  abscess  of  the  kidney:  (1)  Those  associated  wiili 
renal  tuberculosis;  (2)  those  associated  with  stone;  (3)  those  associated  willi 
obstruction  of  the  urinary  flow  in  the  pelvis  of  the  kidney  or  in  the  urinary 
tract  below  it,  coupled  with  an  existing  infection  in  the  urinary  tract;  (4)  those 
in  which  the  abscesses  form  in  the  kidney  substance,  independent  of  infection 
of  the  renal  pelvis,  that  is,  it  may  or  may  not  be  infected. 


474  CHRONIC    SUPPURATIVE   DISEASES    OF    THE    KIDXEY 

Groups  1,  2  and  3  have  been  discussed  in  the  foregoing  part  of  the  chapter 
under  Pyelitis,  Pyelo-nephritis  and  Pyonephrosis,  and  we  have  recognized  the 
fact  that  the  course  of  the  affection  may  he  ascending  or  descending  and  that 
the  predisposing  cause  is  generally  some  obstruction  or  irritation  in  the  renal 
l^elvis  or  below,  that  favors  congestion  in  the  kidney,  and  a  diminislied  resist- 
ance. If  an  abscess  develops  in  the  kidney  substance  proper,  the  infection  may 
he  derived  from  any  part  of  the  body;  but  it  is  usually  due  to  infection  in  the 
lower  urinary  tract. 

Group  4,  in  Avhicli  abscesses  form  in  the  renal  substance  independent  of  in- 
fection in  the  renal  pelvis,  is  the  conditidu  that  will  now  be  considered.  In 
these  cases,  however,  the  same  causes  that  favor  renal  suppuration  exist ;  namely, 
some  obstruction  in  the  renal  pelvis  or  below,  that  interferes  with  the  flow  of 
urine  and  causes  renal  congestion  and  consequent  diminished  resistance  on  the 
part  of  the  kidney.  An  existing  nonsupi)urative  nephritis,  together  with  a 
diminished  resistance,  may  also  provide  this  predisposition. 

These  abscesses  may  then  be  considered  primary,  and,  if  their  contents  are 
discharged  into  the  pelvis  of  the  kidney,  the  condition  of  the  pelvis  favoring  an 
infection,  a  pyelo-nephritis  may  result ;  or  a  pyone^jhrosis  in  case  there  is  a 
large  amount  of  destruction, 

I  will  consider  these  abscesses  of  the  kidney  in  Croup  -i  as  primary  abscesses. 
There  are  two  varieties:  The  miliary  (disseminated)  and  the  circumscribed. 
They  are  of  a  hematogenous  origin  and  pyemic  in  character,  originating  as  sep- 
tic infarcts. 

The  miliary  abscesses  may  invade  the  entire  kidney  cortex  or  only  a  part  of 
it ;  although,  when  they  invade  the  entire  kidney  substance,  they  are  much 
more  marked  in  certain  areas  than  in  others. 

The  circumscrihed  abscesses  may  result  from  the  breaking  down  of  one  or 
more  areas  of  the  miliary  type  into  one  large-sized  abscess  or  into  several ;  or 
they  may  develop  as  localized  abscesses  independent  of  the  miliary  type. 

Etiology. — The  predisj^osing  causes  of  such  kidney  abscesses  are,  as  already 
mentioned,  anything  that  tends  to  produce  congestion  or  to  diminish  the  re- 
sistance of  the  kidney  parenchyma,  such  as  urethral  stricture ;  prostatic  hyper- 
trophy, stone  or  tuberculosis  of  the  prostate ;  stone  or  tumor  of  the  bladder ; 
stone,  tumor,  tuberculosis  or  kinking  of  the  ureter ;  stone,  tumor  or  dilatation 
of  the  pelvis  of  the  kidney,  with  urinary  retention ;  and  stone,  tumor,  patho- 
logical mobility  of  the  kidney  and  also  parenchymatous  or  interstitial  nephritis, 
or  congestion  due  to  infectious  diseases. 

The  active  cause  is  the  introduction  of  pyogenic  germs :  The  colon  bacillus, 
Staphylococcus  aureus.  Streptococcus  pyogenes,  etc.  These  may  come  from 
any  focus  of  suppuration  in  the  body  and  cause  diffuse  miliary  abscesses  of  the 
kidneys,  resembling  those  of  miliary  abscesses  in  the  lungs  in  septic  pneumonia, 
that  is,  of  a  i^yemic  type.     Such  pus-producing  germs  enter  the  kidney  and 


ABSCESS    OF    THE    KIDNEY 


475 


loflgc  in  tlio  fino  r;i]iillarics,  foriiiiiig  innumerable  small  septic  areas.  They 
may  come  from  apjjendiciilar  abscesses,  carbuncles,  septic  metritis  or  endome- 
tritis, septic  endocarditis,  septic  phlebitis  or  many  other  septic  conditions  located 
anywhere  in  the  system.  The  infectious  diseases,  by  lodgment  of  the  specific 
germs  in  the  substance  of  the  kidney,  also  provide  an  active  infection  in  these 
cases. 

Ty])ical  disseminated  abscesses,  varying  from  a  pin  point  to  a  large  pea, 
may  also  develop  in  very  large  numbers  in  patients  who  have  a  suppurative  con- 
dition of  the  loAvcr  genital  tract,  bladder,  prostate  or  urethra. 


Fig.  291. — Multiple  Disseminated  Abscesses  of  Kidney. 
The  kidney  was  7li  inches  long.     Nephrectomy.     (Author's  case.) 

Pathology. — The  kidney  is  swollen  and  increased  in  weight.  In  the  dis- 
seminated forui,  the  removal  of  the  capsule  ex]ioses,  in  the  cortex,  uuiidiers  of 
ju-otruding  abscesses  frequently  surrounded  by  a  hemorrhagic  zone. 

Individual  abscesses  generally  do  not  exceed  the  size  of  a  pea.  Fig.  291 
shows  the  cortex  of  the  kidney  to  be  riddled  with  abscesses  varying  in  size  from 


476  CHROXIC    SUPPUEATIVE    DISEASES    OF    THE   KTDXEY 

a  pin  point  to  a  pea.  When  grouped,  ^vlncll  often  is  the  ease,  the  masses  thus 
formed  may  occupy  a  much  larger  area,  the  size  of  a  filbert  (a  circumscribed 
abscess).  On  incision  of  the  abscesses  (Figs.  292  and  293),  a  greenish-yellow 
pus  exudes,  in  which,  on  microscopic  examination,  the  pyogenic  agent  can  be 
demonstrated.  On  section  through  the  convexity  of  the  kidney,  the  groups  of 
cortical  abscesses  are  found  to  occupy  a  wedge-shaped  area,  the  apex  directed 
toward  the  pelvis.  The  medulla  is  generally  congested  and  travei^sed  by  per- 
pendicular yellow  lines  which  are  continuous  above  with  the  wedge-shaped  foci 
in  the  cortex.  Microscopic  examination  shows  areas  of  necrosis  surrounded 
by  dense,  round-celled  and  polynuclear  leucocytic  infiltration;  the  tubules  are 
filled  with  pus  and  bacteria  and  not  infrequently  also  the  intracapsular  spaces 
and  the  Malpighian  bodies.  Circumscribed  abscesses  may  reach  a  large  size 
involving  both  the  cortex  and  the  medulla  and  may  break  into  the  renal  pelvis 
or  externally  through  the  capsule,  giving  rise  to  a  perinephritic  abscess. 

Symptoms. — The  symptoms  of  miliary  abscess  of  the  kidney  are  mixed 
of  sepsis  and  later  uremia:  Chills,  fever,  sweating,  temperature  from  100°  to 
10.5^  F.,  pulse  90  to  120,  headache,  pain  more  or  less  marked  in  the  loin,  pros- 
tration, loss  of  appetite,  perhaps  nausea  and  vomiting,  and  later  apathy,  stupor, 
delirium,  constituting  a  typhoid  state,  and  occasionally  convulsions. 

Examination. — Upon  examination,  we  find  tenderness  and  perhaps  mus- 
cular rigidity  over  one  or  both  kidneys.  The  urine  is  scanty  and  shows  at  first 
a  trace  of  albumin,  a  few  pus  cells,  renal  epithelia  and  occasional  red  blood 
cells  and  later  casts.  The  blood  shows  no  indications  of  typhoid  fever  or 
malaria,  but  signs  of  sepsis,  e.  g.,  a  leucocytosis  of  from  10,000  to  30,000. 
Ureteral  catheterization  will  usually  show  that  the  albumin  and  cells  come  from 
the  kidney  that  is  painful.  These  kidneys  are  often  found  to  be  enlarged  on 
palpation.  Brewer  has  shoA^m  that  this  type  of  disseminated  miliary  abscess  is 
usually  located  in  one  kidney  at  the  onset. 

Treatment  of  Primary  Abscess  of  the  Kidney. — From  my  experience  in  the 
treatment  of  renal  aL.scesses  occurring  when  no  infection  of  the  renal  pelvis  is 
present,  I  should  say  that  it  is  exceedingly  difficult  to  tell  the  type  of  abscess 
in  the  kidney — ^Avhether  it  be  "disseminated  or  circumscribed,  until  the  organ 
has  been  exposed.  Also  that  it  makes  but  little  difference  whether  or  not  the 
renal  pelvis  is  diseased.  Presumably,  however,  the  disease  at  the  start  is  usu- 
ally disseminated.  The  clinical  observations  of  Brewer,  that  these  disseminated 
abscesses  usually  occur  in  one  organ  at  the  beginning  and  the  more  favorable 
results  that  he  had  with  nephrectomy  than  Avith  nephrotomy  in  these  early  cases, 
would  tend  to  show  that  it  is  important  to  make  an  early  diagnosis  and  to  per- 
form an  early  nephrectomy.  I  think,  therefore,  that  in  operating  on  an  acute 
case  of  short  duration,  if  considerable  kidney  area  is  involved  by  pyemic  ab- 
scesses, large  or  small,  nephrectomy  is  preferable,  if  the  other  kidney  is  healthy. 

If,  in  operating  on  a  case  of  some  duration,  we  find  circumscribed  abscesses 


I 


ABSCESS    OF    THE    KIDXEY 


477 


I 


<  RS 


X 


5    H  J 


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5  i  ^  • 

s  r  a  =? 


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I  p  if     I 


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I.  a  H  S  ^ 

S    H    S    S    S 
O 


478  CHRONIC    SUPPURATIVE    DISEASES    OE    THE    KIDXEY 

present  instead  of  tlio  iniilliplc  miliary  I_ypc3  wlirn  (•()iisi<l('ral)le  healthy  renal 
tissne  is  present,  it  is  a  (piestion  whether  a  nephidloiiiy  or  a  ueplireetoiny  is  in- 
dicated. I  believe,  that  in  sueh  a  ease  it  is  a(l\'isaMe  to  ]i('rf()riii  a  iic]ihrot(iiiiy, 
establish  very  thorongli  drainage  and  do  a  secoiKhiry  nephreetoiiiy  later  if  the 
patient  does  not  improve. 

In  the  case  of  the  patient  Avitli  chronic  parencbymatons  nepbritis  and  a  nniii- 
ber  of  large  circumscribed  abscesses  on  one  side  and  a  kidney  with  interstitial 
nephritis  on  the  other,  wliose  kidneys  I  am  bere  showing  (Figs.  2!)2  and  '2'^)'^), 
the  patient  entered  tbe  bospital  at  4  p.m.  in  a  septic  and  nremic  condition  as 
an  emergency  case.  A  small  amount  of  albumen,  blood  and  ]nis  cells  wei-e 
found  to  come  from  the  enlarged  and  tender  kidney.  Isephrotomy  was  ]n'v- 
formed  a  few  liours  after  entering,  witli  a  fatal  result. 

ACUTE   SUPPURATIVE   NEPHRITIS 

Acute  suppurative  nephritis  is  said  to  be  a  rare  condition,  but  I  l)elieve 
that  there  are  many  more  such  cases  than  is  generally  supposed,  and  that  they 
are  usually  uiistaken  for  other  diseases.     It  is  not  a  true  surgical  condition. 

The  term  acute  suppurative  nephritis  refers  to  a  condition  of  acute  intersti- 
tial inflammation  in  which  numerous  small  ])urulent  foci  are  scattered  through 
the  congested  areas  of  the  kidney  substance.  It  is  usually  hematogenous  in  ori- 
gin, though  it  may  result  from  infection  through  the  lymj^hatics  or  extension  of 
inflammatory  processes  from  the  urinary  tract.  The  etiologic  factors  are  the 
Bacterium  coli,  paratyphoid  and  proteus  bacilli,  Friedliinder's  pneumobacillus 
and  the  pyogenic  cocci,  which  lodge  in  the  lymph  s]iaces  and  smaller  vessels, 
both  of  the  glomeruli  and  intertubular  tissue.  The  invaded  portions  soon 
become  clifl'usely  infiltrated  with  round  and  ])olynuclear  cells  wdiicli  also  enter 
the  lumen  of  the  tubules,  subsequently  reacbiug  the  urine  in  the  form  of  free 
pus  and  pus  casts.  Considerable  areas  of  the  kidney  substance  may  be  involved, 
the  renal  epithelia  often  undergoing  fatty  metamorphosis  and  desquamating.  If 
the  process  is  not  very  active,  the  destructive  changes  may  be  slight,  recovery 
occurring,  after  absorption  of  tbe  pus,  by  regeneration  of  e])ithelium  or  cicatrix 
formation.  If  the  inflammation  is  severe,  cellular  infiltration  may  be  so  intense 
as  to  cause  liquefaction  and  abscess.  The  pus  may  be  either  absorbed  or  dis- 
charged into  the  tubules,  the  abscess  later  healing  by  cicatrization.  Rarely,  the 
process  becomes  chronic,  resulting  iu  the  formation  of  a  large  pus  sac. 

The  symptoms  of  acute  suppurative  nephritis  are  often  very  slight  and  d  i 
not  point  to  a  disease  of  the  kidney,  except  when  the  urinary  examination  is 
made.  Occasionally,  the  patient  complains  of  a  slight  uncomfortable  feeling  in 
the  back  or  loins,  but  this  is  not  always  the  case.  The  patient  may  complain 
also  of  weakness,  loss  of  weight,  strength  and  appetite  and  sometimes  of  head- 
ache.    There  is  acceleration  of  the  pulse  and  increased  temperature.     The  tern- 


ACITTE    STTPPTniATTVE    NEPIIKITIS  479 

pcrature  may  vaiiiic  Iroiii  !»'-•  I<»  10.')  1^\  or  hi^licr,  \'iiryiii^'  Irom  iiii;hl  to  morn- 
ing as  in  typhoid,  and  tlie  ])idse  I'uns  from  70  to  100  and  even  to  120.  The 
l)atieiit  seems  dull,  a])athetic  and  drowsy,  and  other  symptoms  of  a  general 
toxemia  or  a  ('ond)ination  of  sepsis  and  uremia  are  present. 

Examination  may  reveal  tenderness  over  the  kidneys,  and  sr)molim('S  on- 
hirgement. 

The  urine  is  high  colored,  tnrhid,  of  high  specific  gravity;  it  contains  albu- 
min, a  large  amount  of  pus,  granular  and  pus  casts,  the  latter  sometimes  being 
very  numerous.     Urea  is  diminished. 

The  clinical  picture  is  that  of  a  patient  suffering  from  typhoid  fever  or  in  a 
typhoid  state.  The  disease  was  bilateral  in  the  cases  that  I  have  had  under 
observation,  the  involvement  of  both  kidneys  being  in  about  the  same  degree. 
The  patients  were  delirious  part  of  the  time. 

I  advised  operation,  but  the  patients  refused,  and,  after  remaining  in  the 
hospital  for  some  time,  they  were  able  to  sit  up  and  walk  about,  and  were  re- 
moved to  their  homes.  They  recovered  slowly  and  were  able  to  resume  their 
former  occupations.  The  treatment  was  principally  urotropin,  ten  grains, 
t.i.d. ;  milk  and  Vichy  diet ;  saline  laxatives. 

The  diagnosis  depended  on  the  urinary  examination,  clinical  symptoms  and 
ureteral  catheterization. 

Bilateral  nephrotomy  with  drainage  was  recommended.  Xephrotomy  is 
indicated  when  abscesses  form  in  one  or  both  of  these  kidneys,  as  the  condition 
then  becomes  a  surgical  one:  a  single  nephrotomy  if  there  are  abscesses  on.  but 
one  side  and  a  double  nephrotomy  if  on  both  sides.  Suppurative  nephritis  as 
('escribed  in  this  chapter  is,  as  far  as  I  can  learn,  always  bilateral. 


CHAPTER    XXVI 

TUMORS   OF  THE   KIDNEY 

ViECiTow,  in  1863,  first  described  the  difference  pathologically  between  sar- 
coma and  carcinoma.  Fifteen  years  later,  Monti  described  the  difference  be- 
tween the  two  clinically  in  his  article  on  "  Sarcoma  of  the  Kidneys  in  Chil- 
dren." 

Kiister,  in  estimating  the  relative  frequency  of  these  tumors  in  regard  to  age, 
compiled  a  table  which  shows  that  renal  tumors  occurred  with  equal  frequency 
between  the  ages  of  one  and  five  years  and  fifty  and  sixty  years.  Xext  in  fre- 
quency, tumors  were  found  between  the  ages  of  forty  and  fifty  years.  They 
were  more  common  in  men  than  in  women.  Of  601  cases,  318  occurred  in 
men;  the  right  side  was  more  often  affected  than  the  left,  while  both  sides 
were  involved  in  only  twenty  per  cent  of  the  cases, 

Morris  compiled  a  table  of  154  cases  from  the  literatiire,  in  which  he  found 
63  sarcomas,  41  carcinomas,  21  cystic  degenerations,  11  hydatids,  10  adenomas, 
2  myomas,  3  papillomas,  2  lipomas  and  1  dermoid  cyst.  It  will  thus  be  seen 
that,  according  to  these  statistics,  sarcoma  and  carcinoma  make  up  two  thirds 
of  renal  tumors. 

Among  the  tumors  of  the  parenchyma,  adenomas,  carcinomas  and  sarcomas 
are  malignant ;  whereas  lipomas,  fibromas,  myxomas,  angiomas  and  others  are 
nonmalignant.  In  some  cases  of  sarcoma  and  carcinoma,  there  are  almost  no 
symptoms  for  years  and  perhaps  the  whole  of  the  patient's  life  is  free  from 
suffering;  while  in  some  of  the  rapidly  gTowing  lipomas  and  fibromas  and  other 
tumors,  life  is  ended  in  a  few  months. 

NONMALIGNANT   TUMORS 

!N"onmalignant  tumors  are  of  very  rare  occurrence  in  the  kidney  and  their 
importance  is  proportionately  small.  Their  presence  may  pass  unrecognized 
for  a  certain  length  of  time,  especially  when  the  growth  is  of  small  size.  Their 
benign  character  cannot  be  positively  established  until  the  kidney  has  been  ex- 
posed, the  nodule  incised  and  a  part  of  it  examined  under  the  microscope,  if 
necessary.  The  treatment  may  be  conservative  Tpartial  nephrectomy)  in  the 
rare  cases  where  the  tumor  is  positively  known  to  be  benign  in  character,  and 
480 


\ 


MALIGNANT    TUMORS  481 

where  only  a  circuiiisei'ibcd  portion  of  the  kidney  is  in\-olve(i  ;  (ji-  radical  (total 
nephrectomy),  whenever  the  microscope  shows  even  the  slightest  suggestion  of 
malignancy. 

The  following  henign  growths  have  been  found  in  the  kidney: 

(1)  Lipoma,  (2)  fibroma,  (3)  myxoma,   (4)  angioma,   (5)  adenoma. 

1.  Lipoma. — Lipomas  of  the  kidney  may  be  of  two  kinds:  (a)  Fatty  new 
growths  formed  by  a  metamorphosis  of  the  renal  interstitial  tissue,  and  (h) 
lipomas  gi'owing  from  the  capsule.  The  former  are  small,  grayish-yellow,  lobu- 
lated,  rounded  growths  found  in  the  cortex  and  almost  always  contain  nonstriated 
muscular  fibers.  According  to  Virchow,  they  rise  from  the  connective-tissue 
stroma  of  the  organ  and  must  be  carefully  distinguished  from  the  circumscribed 
fatty  degeneration  of  the  renal  parenchyma.  Both  kinds  may  be  due,  however, 
to  fetal  inclusions.     Degeneration  into  sarcomas  has  been  observed. 

2.  Fibroma. — Fibromas  are  found  in  the  kidney  as  small,  hard,  nsually 
multiple,  encapsulated,  fibrous  masses  in  the  medulla  or  cortex.  In  rare  cases, 
they  attain  a  considerable  size  and  are  subcapsular,  giving  rise  to  cystic  forma- 
tions. 

3.  Myxoma. — The  benign  myxoma  is  exceedingly  rare  in  the  kidney,  but 
myxosarcoma  is  more  common.  These  gTOwtbs  contain  masses  of  mucoid  cells, 
which  have  substituted  areas  of  the  sarcomatous  tissue  and  are  grouped  in  a  fine 
fibrous  stroma. 

4.  Angioma. — True  vascular  growths  of  the  kidney  are  of  exceptional  occur- 
rence. They  are  usually  of  small  size  and  lie  beneath  the  capsule  of  the  kidney, 
presenting  the  form  of  scarlet  or  purplish  clusters. 

5.  Adenoma. — Adenoma  of  the  kidney  occurs  in  two  varieties,  the  small  and 
the  large,  which  latter  is  usually  malignant.  The  highly  vascularized  form  es- 
pecially has  a  marked  tendency  to  malignancy.  The  structure  of  adenomatous 
growths  simulates  the  structure  of  normal  tubules,  presenting  the  appearance  of 
separate  or  multiple  nodules  with  distinct  outlines.  Small  benig-n  adenomas  are 
small  nodules  occurring  in  kidneys  affected  with  chronic  nephritis,  where  they 
appear  as  prominent  reddish-gray  nodes  under  the  capsule,  varying  in  size  from 
the  head  of  a  pin  to  a  hickory  nut.  They  are  generally  circumscribed,  encapsu- 
lated, and  may  dip  into  the  cortex.  Their  clinical  significance  is  not  important, 
and  they  simply  occur  in  chronic  nephritis,  as  is  shown  at  autopsy. 

MALIGNANT   TUMORS 

Etiology. — Little  is  known  about  the  etiology  of  malignant  tumors  of  the 
kidney.  We  have  already  considered  the  ages  at  which  they  generally  occur. 
They  are  more  common  in  males  than  in  females.  Traumatism  has  been  consid- 
ered as  a  predisposing  cause  by  some.  Hypernephroma  is  a  tumor  originating 
from  the  adrenal  tissue,  developing  either  in  the  suprarenal  gland,  or  more  com- 


482 


TUMORS    OF    THE    KIDNEY 


monlj  as  an  ectopic  growth  within  the  kidney.  It  is  practically  limited  to  this 
organ,  but  occasionally  occurs  in  other  parts  of  the  hody,  as  the  bones,  lungs, 
liver,  uterus  and  ovary.  This  variety  of  renal  tumor  is  in  a  class  by  itself, 
and  may  not  be  considered  a  true  renal  tumor,  as  it  cannot  be  classified  under 
cither  ej^ithelial  or  connective-tissue  neoplasms.  It  is,  nevertheless,  a  tumor 
of  the  kidney,  and  should  be  classified  as  such,  even  if  its  pathology  is  difi^erent 
from  that  of  malignant  neoplasms. 

Pathology. — General  Coa^sidekations. — Malignant  tumors  may  be  pri- 
mary or  secondary.  The  characteristic  of  the  primary  growths  is  their  ra])id 
increase  in  size,  their  tendency  to  metastasis,  and  their  inclination  to  become 
generalized  and  to  produce  cachexia.    They  may  be  single  or  multiple. 

Special  CoisrsiDEEATiOisrs. — Malignant  Adenoma. — The  malignant  variety 
of  adenoma  is  usually  of  the  papillary  type,  whereas  the  alveolar  type  is  more 
common  in  benign  adenomas.  The  growths  appear  as  soft,  white  friable  nodules, 
varying  in  size  from  a  pea  to  a  small  orange.  They  are  situated  in  the  cortex  of 
the  kidney  beneath  the  capsule,  which  they  lift  np.  They  often  have  a  thick 
capsule  of  their  own  with  septa  and  may  contain  the  results  of  hemorrhagic  or 
cystic  degeneration.  Malignant  adenoma  develops  from  the  epithelia  of  the 
renal  tubules  and  gives  rise  to  the  same  symptoms  as  cancerous  neoplasms.  A 
transition  form  is  represented  by  the  adeno-carcinomas. 


Fig.  294. — Cahcinoma  of  the  Kidney.     Size  of  organ,  &'^i  by  4  inches.     Man,  age  sixty.     It  was 
movable  and  situated  below  the  umbilicus.      (Author's  case.) 


Carcinoma. — Carcinoma  varies  both  in  size  and  apj^earance.     The  tumor 
is  more  or  less  well  defined  and  encapsulated,  although  the  growth  occasionally 


MALIGNANT    TUMORS 


483 


infiltrates  the  renal  parenchyma,  causing  enlargement  of  the  organ   as  well. 
The  size  varies  between  a  hickory  nut  and  a  melon,  generally  with  a  nodular 
surface  (Fig.  294).     On  section,  the  growths  appear  as  yellowish-white  masses, 
divided  into  lobes  and  nodules  by  fibrous  septa  arising  from  the  capsule.     Hem- 
orrhagic and  cystic  areas  arc  ])resent  in  some  cases.     The  tumor  si)reads  by  con- 
tinuity, giving  rise  to  adhesions  in  the  surrounding  structures.    The  fatty  capsule 
is  quite  adherent  to 
the    growth,    which 
tends  to  spread  for- 
Avard,    pushing    the 
intestines  in  front  of 
it.    Metastasis  takes 
place     through     the 
lymphatic     system 
and  the  veins.     The 
liver,   Inugs,   glands 
of  the  hilum  and  re- 
troperitoneal glands 
are   often   involved. 
The  tumor  is  of  the 
epithelial    type    and 
has    a    marked    ten- 
dencA'  to  undergo  de- 
generative changes. 
Sarcoma. — Sar- 
coma is  the  most  fre- 
quent type  of  renal 
tumor  and  is  of  con- 
nective-tissue oriffin, 
that  is,  derived  from 
the  stroma  of  the  or- 
gan.    These  growths 

usually     appear     on       Fig.  295.— Sarcoma  of  the  Kidney.     The  tumor  at  the  time  of  the 
one     side       cenerallv  operation  was  very  large,  of   a   fragile  and  friable  texture,   and  the 

'     *="  '     '  hemorrhage  was  alarming.     It  was  very  large.     (Author's  case.) 

the    left,     and     are 

most  common  in  children,   females  being  more  frequently   affected.      Senator 

reports  58  cases,  35  of  which  occurred  in  children  under  six  years  of  age. 

The  tumors  are  usually  indiedded  in  the  kidney  substance  and  are  often  cir- 
cumscribed and  inclosed  in  a  well-defined  capsule.  Sometimes  they  are  diffused 
through  the  kidney,  or  they  may  be  surrounded  by  a  thin  layer  of  parenchynui 
(Fig.  295).  On  section,  they  ap])ear  lobulated  and  vary  greatly  in  size,  some- 
times reaching  enormous  proportions.     They  may  spread  to  the  ureters  and  rena] 


484  TUMORS    OF    THE    KIDXEY 

vessels,  the  retroperitoneal  glands,  the  lungs,  the  liver  and  other  tissues.  Sar- 
comas may  be  of  any  variety,  small  and  large,  round-celled,  giant-celled,  spindle- 
celled,  and  melano-sarcomas.  Mixed  growths,  like  adeno-sarcoma,  myosarcoma 
and  other  forms,  have  also  been  found.  The  presence  in  such  mixed  growths 
of  striated  muscle  fibers  and  of  cartilage  cells  has  been  explained  as  embryonic 
inclusions  of  neighboring  tissues,  or  the  result  of  sarcomatous  degeneration  of 
a  dermoid  at  some  stage  of  its  development. 

Bli  ah  do  myoma. — This  extremely  malignant  growth  was  first  identified  by 
Rokitansky  in  1848,  and  later  on  received  the  special  attention  of  Eberth  (1872  J 
and  Cohnheim  (1875).  Its  occurrence  is  practically  limited  to  the  period  be- 
tween the  first  and  third  year  of  infancy.  The  tumor  is  characterized  by  the 
presence  of  long  slender  cells,  with  more  or  less  well-marked  transverse  striation, 
which  have  been  explained  as  the  result  of  fetal  inclusion. 

Hypernephroma. — The  true  character  and  origin  of  these  tumors  was  shown 
by  Grawitz  (1883)  who  first  differentiated  them  from  lipomatous  gTowths  of 
the  kidney  and  pointed  out  their  heterotopic  evolution  upon  the  basis  of  aberrant 
fragments  of  supra-renal  tissue  structures  resembling  those  of  suprarenal  neo- 
plasms. His  arguments  were  opposed  by  Ludeck  who  considered  these  tumors 
as  adenomas  or  adeno-sarcomas,  and  by  Hildebrand  who  considered  them  as 
endotheliomas.  Grawitz  proposed  the  name  of  struma  lipomatodes  aberrantte 
renis.  It  was  changed  to  hypernephroma  by  Lubarsch  in  1S9G.  The  growth 
(Figs.  296  and  297)  is  practically  limited  to  the  kidney,  Avhere  it  rises  from  the 
portion  of  the  suprarenal  body,  variable  in  size,  which  during  embryonic  life  has 
remained  under  the  capsule  of  the  kidney  or  within  the  medullary  substance.  It 
is  considered  by  some  authors  as  the  most  common  form  of  malignant  disease  of 
the  kidney.  According  to  Albarran  and  Imbarth,  seventeen  per  cent  of  kidney  tu- 
mors were  found  to  be  hypernephroma.  The  average  age  of  patients  is  about  fifty. 

The  histology  of  hyijernephroma  is  very  variable,  and  depends  upon  the 
size  of  the  neoplasm,  as  well  as  the  metamorphosis  it  has  undergone.  A  small 
tumor,  as  a  rule,  presents  the  picture  of  the  cortical  substance  of  the  normal 
suprarenal  body.  Fatty  infiltration  of  the  cells  is  common,  and  drops  of  fat  are 
often  quite  plainly  visible.  This  accounts  for  the  yellow  color  of  the  tumor, 
which  for  this  reason  was  formerly  supposed  to  be  a  liponui.  ^Malignant  hyper- 
nephroma either  possesses  the  structure  just  described  or  it  duplicates  the  pic- 
ture of  alveolar  neoplasms  or  of  sarcoma,  as  a  result  of  the  exuberant  cellular 
proliferations.  These  tumor  cells  differ  from  normal  cells  by  their  elongated 
polygonal  shape. 

The  malignant  character  of  hypernejdiroma  is  shown  by  the  presence  of 
necrosis  and  the  fatty  or  colloid  degeneration  locally,  together  with  the  resulting 
destruction  of  the  surrounding  tissues  and  organs,  the  penetration  into  the  veins, 
and  the  formation  of  metastases  along  the  venous  circulation.  This  marked 
tendency  to  fatty  degeneration  and  retrogressive  changes  is  especially  character- 


MALIGNANT    TUMOKS 


485 


istic  of  liypernei)hroma.  The  tumor  usually  occupies  the  u])i)er  pole  of  the 
kiduey.  It  is  generally  small,  about  the  size  of  a  pea,  and  only  iu  an  advanced 
period  of  life  (usually  forty-five)  reaches  a  size  sufficient  for  recognition.  ]t  is 
more  connnonly  found  in  men. 

Fio.  296. 


Fig.   297. 
Fig.  29(3. — Hypernephroma,  Out.side  View.     The  kidney  was  8 '4  inches  lung.     (.\uthor's  case.) 
Fig.  297. — Hypernephroma,  View  on  Section.     (Author's  case.) 


486  TUMORS    OF    THE    KIDNEY 

Metastasis  of  liyperiiephroina  of  I  lie  kidney  lias  been  observed  in  practically 
every  organ  and  tissue  of  the  body.  The  bones,  lungs  and  the  liver  seem  to  be 
the  scat  of  predilection  for  secondary  growths  of  this  character.  The  venous 
circulation  constitutes  the  open  avenue  for  the  occurrence  of  metastatic  h^'por- 
ncphroma.  Less  frequently,  metastasis  occurs  through  the  lymphatic  circula- 
tion. In  metastatic  hypernejjhi'dma,  the  glands  of  the  lymphatic  system  are 
either  entirely  free  from  secondary  growths,  or  an  infection  of  the  retro^ierito- 
neal  glands  is  present. 

Symptoms. — It  is  convenient  to  consider  the  symptoms  of  these  malii>iiant 
tumors  without  reference  to  their  variety,  inasmuch  as  it  is  generally  impossible 
to  make  a  clinical  distinction  between  thorn.  Symptoms  may  be  absent  for 
months  or  years,  but  when  they  begin  to  appear,  they  usually  progress  rapidly, 
and  the  patient  dies  in  from  one  to  three  years  of  cachexia,  asthenia,  nremia, 
intestinal  obstruction,  or  peritonitis.  The  symptoms  are  hematuria,  enlarge- 
ment, pain,  changes  in  the  urine  and  symptoms  of  pressure  on  other  organs. 
Hematuria  is  the  most  important  symptom  and  occurs  in  from  fifty  to  eighty 
per  cent  of  the  cases,  varying  in  the  time  of  its  appearance,  its  duration  and 
frequency.  It  occurs  without  apparent  cause,  probably  due  to  the  fragility  of 
the  renal  blood  vessels  induced  by  the  neoplastic  changes,  while  in  the  later  stages 
it  is,  probably  the  result  of  congestion  or  nlceration  into  the  renal  calices  or 
tubules.  The  bleeding  generally  becomes  more  profuse  and  more  frequent  as  the 
disease  advances,  and  it  is  more  abundant  than  in  any  other  class  of  renal  dis- 
ease. The  urine  is  uniformly  reddened,  and  ureteral  clots  of  a  worm  shape  are 
frequently  present.  Considerable  blood  may  at  times  he  found  microscopically 
when  the  urine  is  not  reddened. 

Tumefaction  in  the  loin  is  not  always  felt,  as  the  growth  may  he  too  small 
or  situated  too  high  up  in  the  kidney  to  be  well  palpated.  When  it  can  be  fcU, 
however,  it  moves  with  respiration,  has  an  irregular  feel,  can  easily  l)e  ballntted 
and  can  often  be  better  felt  when  the  patient  is  lying  on  the  healthy  side  with 
the  thighs  somewhat  flexed. 

The  pain  of  renal  tumors  is  of  little  diagnostic  value.  It  is  not  always 
present  and  varies  considerably  in  duration  and  character.  It  may  bo 
acute  and  spasmodic,  but  is  more  usually  a  dull  persistent  ache,  causing  a 
sense  of  discomfort  in  the  loin.  Tenderness  is  present  in  proportion  to  the 
pain. 

The  urine  shows  the  inflammatory  state  and  functional  impairment  of  the 
kidney.  Albumin  is  often  present  and  the  amount  of  urea  lessened,  while  the 
specific  gravity  varies.  Pus  is  foimd  in  infected  cases.  The  most  important 
point  in  connection  with  the  urine  in  these  cases  is  the  presence  of  characteristic 
cells  of  the  growth  in  the  microscopic  sediment.  These  cells  are  irregular  in 
shape,  atypical  in  character,  not  like  the  ordinary  epithelia  of  the  genito-nrinary 
tract,  and  sometimes  show  fatty  degeneration.     Blood  cells  and  casts  are  often 


MALIGNANT    TUMORS  487 

present  wlien  the  urine  shows  no  visible  signs  of  hematuria.  The  corpuscles  are 
sometimes  pale  and  devoid  of  hemoglobin. 

Pressure  symptoms  are  due  to  pressure  of  the  growth  upon  the  adjoining 
tissues,  giving  rise  to  various  disturbances.  When  it  is  exerted  on  the  nerve 
plexuses,  such  as  the  spermatic  and  ovarian  plexus,  sensations  of  pain  are  felt  in 
the  groin  and  the  testes,  or  the  uterus  and  ovaries.  When  the  gastric  and 
splanchnic  plexuses  are  involved,  abdominal  distress  is  also  present.  Pressure 
upon  the  vena  cava  causes  edema  of  the  lower  extremity,  whereas  pressure  on 
the  renal  vein  on  the  left  side  often  gives  rise  to  an  enormous  varicocele.  Ca- 
chexia is  a  late  symptom. 

The  symptoms  of  hypernepJiroma  are  practically  the  same  as  those  of  the 
malignant  tumors  of  the  kidney  just  considered.  The  evolution  of  the  tumor 
is  very  gradual  and  it  is  very  characteristic  of  this  form  of  renal  neoplasm 
that  it  usually  does  not  give  rise  to  any  symptom  before  the  fiftieth  year,  except- 
ing occasional  attacks  of  dragging  pains  and  sensations  of  pressure.  The  first 
reliable  symptom  is  a  characteristic  hematuria,  which  appears  spontaneously 
and  ceases  just  as  suddenly.  In  the  average  case  of  hypernephroma,  spontaneous 
hematuria  occurs  for  the  first  time  about  five  or  six  years  after  the  first  pain  is 
experienced.  Generally,  the  hematuria  is  preceded  by  an  obscure  sensation  of 
pressure  and  the  patient  readily  points  out  the  affected  side  in  the  majority  of 
cases.  The  hematuria  has  the  same  characteristics  as  that  of  the  other  malig- 
nant tumors  of  the  kidney.  Pain  is  present  at  some  stage  of  the  trouble  in 
eighty  per  cent  of  all  cases  and  shows  all  degrees  from  a  dull  diffuse  backache  to 
severe  renal  colic.  It  may  be  the  first  symptom  noticed  and  sometimes  remains 
the  only  one.  Tenderness  on  pressure  is  frequently  present,  especially  over  the 
site  of  the  growth.  The  tumor  usually  does  not  give  rise  to  any  trouble  until  it 
begins  to  press  upon  the  neighboring  organs,  or  to  produce  dragging  sensations 
on  account  of  its  increasing  weight.  Its  growth  is  far  from  uniform  and  years 
may  pass  before  it  noticeably  increases  in  size.  It  may  then  start  another  rapid 
growth,  giving  rise  to  severe  hemorrhage.  In  most  cases,  the  tumor  is  a  late 
symptom.  It  is  interesting  to  note  that  cases  have  been  described  in  which  twenty 
to  thirty  years  lay  between  the  first  evidence  of  pain  and  the  discovery  of  the 
growth.  It  may  reach  the  size  of  a  cocoanut  or  a  small  pumpkin.  It  is  quite 
freely  movable.  The  bronze  discoloration  of  the  skin,  characteristic  of  Addi- 
son's disease,  has  only  been  occasionally  noticed,  even  in  advanced  stages  of  this 
condition.  The  course  of  the  trouble  is  irregular ;  it  may  remain  practically 
latent  for  a  number  of  years,  and  active  proliferation  may  be  set  up  at  any 
time  by  abnormal  conditions  of  the  organism,  such  as  general  disease  or 
traumatism. 

Diagnosis. — This  includes  detection  of  the  presence  of  the  tumor,  sec- 
ondary metastatic  deposits,  and  the  variety  of  the  growth.  It  is  necessary  to  dif- 
ferentiate the  condition  from  renal  tuberculosis,  stone,  movable  kidney,  hydro- 


488  TUMORS    OF   THE   KIDNEY 

noplirosis,  pyonephrosis,  nbdoniiiial  tumors,  bladder  tumors  and  lieinatnria  from 
other  causes. 

Tubcrenhn-  kidney  generally  gives  rise  to  a  similar  hematuria,  but  this  is  not 
80  abundant;  also  to  a  tumefaction  that  resembles  it  greatly,  but  in  tuberculosis 
the  development  of  a  swelling  is  more  rapid.  The  bladder  and  genital  tract 
in  tuberculosis  are  often  involved,  as  well  as  are  other  tissues  of  the  body. 
The  urine  contains  tubercle  bacilli,  it  is  more  often  purulent,  and  is  free  from 
tumor  cells.  A  febrile  condition  is  often  present,  and  there  is  a  response  to  the 
guinea-pig  injection. 

Eenal  calculus  gives  rise  to  hematuria,  but  it  is  usually  due  to  exercise, 
is  more  intermittent,  of  shorter  duration  and  the  pain  is  of  greater  severity. 
The  urine  shows  more  crystals,  is  more  liable  to  have  pus  present  and  contains 
no  tumor  cells,  while  the  presence  of  stone  is  generally  shown  by  radiography. 
There  is  no  cachexia. 

A  tumor  of  the  bladder  gives  rise  to  hematuria,  in  which  case  the  blood  is 
not  so  well  mixed  with  the  urine,  and  the  clots  are  irregular  and  not  of  the  worm- 
like character  found  in  renal  cases.  The  urine  contains  tumor  cells,  but  the 
other  products  of  irritation  and  inflammation  found  are  from  the  bladder  and 
not  from  the  kidney.  The  presence  of  tumor  is  shown  by  the  cystoscope,  whereas 
no  evidence  of  renal  growth  is  furnished  by  ureteral  catheterization. 

Hydronephrpsis  rarely  causes  hematuria.  On  ureteral  catheterization,  ob- 
stacles may  be  found  in  the  ureter ;  but  if  the  catheter  passes  to  the  kidney,  a 
quantity  of  retained  urine  will  be  obtained,  with  a  low  specific  gravity  and  con- 
taining urea. 

Pyonephrosis  does  not  occasion  hematuria,  unless  due  to  stone  or  tuber- 
culosis. It  is  more  frequently  painful.  It  may  be  accompanied  by  fever, 
either  continuous  or  periodical.  There  may  be  an  obstacle  in  the  ureter,  pros- 
tate or  urethra  on  catheterization ;  and  a  retention  of  fluid  containing  pus  is 
usually  found  in  the  kidney  on  ureteral  catheterization. 

Other  abdominal  tumors  are  differentiated  by  a  negative  examination  of  the 
urinary  organs.  If  we  feel  a  tumor  in  the  position  Avhich  might  be  occupied 
by  the  kidney  and  find  normal  urine,  no  stricture,  no  enlargement  of  the  pros- 
tate, a  healthy  bladder,  no  urinary  retention,  free  ureters,  no  retention  in  the 
pelvis  of  the  kidney,  we  can  assume  that  the  disease  is  extrarenal  and  inde- 
pendent of  the  kidney. 

Perinephritic  abscess  may  at  times  be  confused  with  renal  tumor.  If  this 
is  due  to  renal  trouble,  there  are  usually  evidences  of  such  trouble  in  the  urine. 
The  condition  from  which  it  arises  is  generally  a  renal  tuberculosis  or  a  cal- 
culus, which  we  would  be  able  to  determine  by  the  findings  already  mentioned. 
The  tumor,  moreover,  is  not  well  rounded,  it  cannot  be  ballotted  and  constitu- 
tional symptoms  are  present. 

Tumors  of  the  liver  are  generally  characterized  by  a  dullness  extending 


1 


MALIGNANT    TUMORS  489 

from  tlic  livci"  downwai'd  onto  the  ('iilargciiiciit,  unless  llicy  fomo  from  the 
midtllo  or  ))osterior  ])ai't  of  \\\c  organ,  when  they  are  ditHciilt  1o  differentiate 
from  a  renal  tumor.  They  cannot,  however,  he  so  well  hallotted.  Besides 
this,  the  nrinc  is  normal,  except,  perhaps,  when  there  is  an  increased  amount 
of  bile. 

Gall-bladder  tumors  are  not  common  and  of  smaller  size;  the  urine  is  nor- 
mal, while  the  stools  are  liable  to  be  of  a  characteristic  claylike  color. 

Splenic  tnniors  are  dull  on  percussion,  extending  downward  and  inward  ; 
the  border  of  the  tumor  is  usually  sharper,  whereas  hematuria  and  renal  ele- 
ments are  absent.  Large  ovarian  cysts  and  tumors,  as  well  as  those  from  the 
uterus,  grow  from  below  upward,  instead  of  from  above  downward  like  renal 
tumors.     They  can  be  detected  in  both  vaginal  and  abdominal  palpation. 

There  are  other  varieties  of  renal  hematuria  resembling  that  of  tumor, 
which  are  painless,  occur  independent  of  exertion  and  are  associated  with  an 
abundant  loss  of  blood.  They  are  spoken  of  as  essential  hematurias  and  are 
usually  due  to  a  chronic  unilateral  nephritis.  The  kidney,  however,  cannot 
be  felt. 

In  hypernephroma,  the  chief  diagnostic  difficulties  consist  in  the  chronic 
and  jDractically  painless  evolution  of  the  tumor,  together  with  its  usual  location 
at  the  upper  pole  of  the  kidney.  Palpation  is  sometimes  easier  when  the  pa- 
tient is  placed  on  the  healthy  side  with  the  thighs  partially  flexed.  During  the 
patient's  respiratory  movements,  the  examining  hand  must  endeavor  to  reach 
up  as  high  as  possible  in  the  diaphragm.  In  this  Avay,  the  organ  may  fre- 
quently be  grasped  and  outlined,  unless  the  abdominal  wall  is  very  muscular 
or  fat.  Exploratory  incision  in  the  lumbar  region  is  advisable  when  the  disease 
is  suspected. 

Prognosis. — Unless  operated  upon,  malignant  renal  tumors  are  usually  fatal 
within  four  years  after  their  detection.  Relapses  are  very  frequent,  usually 
coming  on  within  six  months,  but  sometimes  not  for  a  number  of  years. 

It  is  difficult  to  predict  the  outcome  in  any  given  case  of  hj^pernephroma, 
on  account  of  its  peculiar  erratic  and  irregular  course.  It  may  remain  latent 
as  long  as  the  patient  lives ;  but  when  the  malignancy  asserts  itself,  the  disease 
is  progressive  and  generally  terminates  fatally  in  less  than  three  years.  Death 
has  been  observed  as  early  as  six  weeks  after  the  onset  of  the  acute  symptoms. 
Surgical  prognosis  is  far  from  favorable.  The  immediate  mortality  after  opera- 
tion may  reach  fifty  per  cent.  On  the  other  hand,  patients  may  li\-e  for  a  few 
months  or  a  few  years. 

Treatment  (Nephrectomy). — In  children,  the  transperitoneal  route  is 
elected  by  some,  because  it  gives  better  access  to  the  growth  ;  the  hnnbar  route 
is  preferable  in  adults.  Albarran  states  that  the  mortality  is  twenty-two  per  cent 
in  adults,  and  twenty-five  per  cent  in  children.  These  statistics  include  twenty- 
two  operations  upon  adults,  three  of  whom  were  in  good  condition  more  than  four 


490 


TUMORS    OF    THE    KIDNEY 


years  after  the  operation.     He  knows  of  only  seven  nephrectomies  in  chihlren, 
with  the  patient  survivino-  the  operation  three  years  or  longer. 

The  treatment  of  hyi)crne])hronia  is  similar  to  that  of  other  malignant 
growths  of  the  kidney,  and  consists  in  nephrectomy,  as  soon  as  the  other  kidney 
has  been  shown  by  a  cystosco])ic  and  ureteral  catheterization,  with  chemical  and 
microscopical  examination  of  the  urine,  to  be  sufficiently  healthy  to  carry  on 
the  renal  function. 


1  ii,.  J98. — Papilloma  of  the  Renal  Pelvis. 

The  presence  of  metastases  is  a  contraindication  to  operation.  The  growth 
is  usually  removed  by  lumbar  incision,  which  may  be  extended,  if  necessary,  by 
dissecting  the  eleventh  and  twelfth  ribs.  The  fatty  capsule  also  should  be  re- 
moved. Laparotomy  is  advocated  by  some  operators.  Profuse  hemorrhage 
from  the  large  blood  vessels  in  the  capsule  or  from  the  soft  and  injured  tissues 
frequently  causes  alarming  symptoms,  so  that  every  precaution  should  be  ex- 


PERIRENAL   TUMORS  491 

oroised   to  meet  severe  c-oiiiplicatidiis   liy  means  of  saline   infusions  and  other 
methods. 

TUMORS    OF   THE   PELVIS    OF   THE    KIDNEY 

There  are  al)ont  forty-five  cases  of  tumors  of  the  pelvis  of  the  kidne}'  on  rec- 
ord (Albarran,  Aim.  des  inal.  des  of(j.  (jcnito-nrin.,  11)00,  p.  701).  These 
tumors  may  originate  in  the  kidney  and  subsequently  invade  the  pelvis,  or  they 
nuiy  arise  in  the  pelvis  itself.  The  most  common  forms  of  the  last  class  are  sim- 
ple papilloma  and  epithelioma  (Morris,  loc.  cit.,  II,  I).  Fig.  298  shows  a 
papilloma  of  the  pelvis.  Carcinoma,  myxoma,  myxosarcoma,  lymphatic  endo- 
thelioma, myosarcoma  and  rhabdomyoma  have  also  been  found  originating  in 
the  jielvis. 

The  growths  often  extend  into  the  ureter.  In  these  cases,  there  will  be 
found  symptoms  of  urinary  obstruction,  with  all  their  consequences — such  as 
hydronephrosis  and  suppnrative  diseases. 

The  diagnosis  between  pelvic  and  renal  new  growths  cannot  be  made,  as 
a  rule,  unless  the  ureteral  catheter  dislodges  jjortions  of  a  villous  growth 
(papilloma)  from  the  pelvis,  or  the  urine  contains  such  structures  in  abundance, 
as  shown  by  the  microscope. 

The  progTiosis  of  malignant  tumors  of  the  renal  pelvis  is  just  as  unfavor- 
able as  that  of  the  same  growths  in  the  kidney.  The  prognosis  of  benign  tumors 
(papilloma)  of  the  pelvis  is  not  favorable,  on  account  of  the  danger  of  trans- 
formation into  epithelioma. 

I^ephrectomy  at  an  early  stage  is  the  only  mode  of  treatment  to  be  depended 
upon  in  these  eases.  Although  the  immediate  results  of  surgical  interference 
are  favorable,  a  recurrence  or  a  transformation  to  malignancy  of  a  benign 
growth,  in  the  ureter  or  elsewhere,  is  probable,  and  the  danger  persists  for  years 
after  the  removal  of  the  diseased  kidney. 

PERIRENAL   TUMORS 

This  class  of  neoplasm  occurs  in  the  fibrous  or  the  fatty  capsule.  Albarran 
collected  thirty-one  cases  of  this  kind  from  the  literature,  and  states  that  the 
symptoms  did  not  vary  from  those  of  the  corresponding  tumors  of  the  kidney 
proper.  Lipomas,  fibro-lipomas  and  sarcomas  are  the  most  common  varieties. 
Barring  sarcoma,  all  these  growths  are  characterized  by  their  very  gradual 
development. 


b 


CHAPTER    XXVII 

CYSTS  OF  THE  KIDNEY 

Eeistal  cysts  are  comparatively  rare.  They  are  on  the  border  line  between 
medicine  and  surgery,  in  that  some  are  associated  with  nephritis  and  require 
medical  treatment  only,  wdiile  others  are  in  need  of  surgical  interference. 

We  have  the  folloAving  varieties  of  cysts  of  the  kidney : 

(1)  Xephritic  cysts  (cysts  of  sclerosed  kidneys). 

(2)  Serous  cysts. 

(3)  Agglomerate  cysts  (polycystic  kidney). 

(4)  Hydatid  cysts. 

(1)  Cysts  Due  to  Interstitial  Nephritis. — Cysts  due  to  interstitial  nephri- 
tis are  very  small,  ranging  in  size  from  a  pinhead  to  a  small  pea.  They  are 
usually  multiple,  and  constitute  a  medical  rather  than  a  surgical  condition. 
These  nephritic  cysts  are  due  to  compression  of  some  urinary  tubules  by  the 
new  growth  of  connective  tissue,  and  to  the  dilation  of  the  tulmles  behind  the 
constriction.  The  existence  of  these  cysts  should  be  borne  in  mind  when  operat- 
ing on  the  kidney,  and  they  should  not  be  confused  with  cystic  degeneration  of 
the  organ. 

(2)  Large  Serous  Cysts. — Large  serous  cysts  arc  usually  single,  and  as  a 
rule  found  in  but  one  kidney ;  if  multiple,  they  do  not  occur  in  great  numbers, 
probably  not  more  than  four  or  five  in  one  organ  (Fig.  299).  They  vary  in 
size  from  an  egg  to  that  of  a  child's  head.  They  have  a  moderately  thin  wall, 
with  a  smooth  exterior,  while  the  adjoining  renal  substance  is  sometimes  hol- 
lo-sved  out  by  their  pressure. 

They  are  filled  with  yellow  liquid  of  variable  consistence,  which  generally 
has  a  high  proportion  of  albumin  and  of  urea,  with  a  variable  admixture  of 
phosphates.  The  cystic  fluid  S(.)mctimcs  contains  cholesterin  crystals  and  leu- 
cin  balls,  more  rarely  uric  acid. 

The  cyst  wall  is  made  up  of  connective  tissue  lined  with  cuboid  or  flattened 
epithelial  cells.  In  the  immediate  surroundings  of  the  cyst,  the  kidney  tissue 
presents  sclerotic  changes. 

Diagnosis. — Serous  cysts  of  the  kidney  do  not  give  rise  to  a  clearly  defined 
set  of  symptoms  and  therefore  are  diflicult  to  diagnosticate.  The  two  signs 
492 


LARGE    SEROUS    CYSTS 


493 


usually  ]iresont  are  sliiilit  ])aiii  and  a  swell iui;'  in  the  alidniiicii  on  the  affected 
side.  The  tumor  is  found  to  be  in  the  reo'ion  of  the  ki<hiey  and  is  sli<:iiily 
tender  on  ])ressure.  It  is  often  stated  that  fluctuation  is  present  in  the  tumor, 
but  I  think  that  the  tension  is  too  great  usually  to  permit  of  such  findings. 


Fig.  299. — Large  Serous  CrsT  of  the  Kidney.     Size  7}-i  by  8  inches.     (Author's  case.) 

Serous  cysts  of  the  kidney  are  sometimes  confounded  with  ovarian  cysts, 
but  differ  from  the  latter  in  their  form  of  growth,  which  is  from  above  down- 
ward instead  of  from  below  upward,  and  also  in  the  absence  of  signs  on  vaginal 
palpation.  Sometimes  one  of  these  kidneys  is  found  in  the  pelvic  cavity  in 
case  it  has  become  displaced  there  and  is  retained  by  adhesions,  as  was  the  case 
shown  in  this  chapter.  Ureteral  catheterization  is  the  safest  method  of  distin- 
guishing these  cysts  from  hydronephrosis  or  ])voue])ln-osis,  as  in  the  latter  cases 
if  the  instrument  can  be  passed  into  the  renal  ]telvis,  then  the  tuiiKU'  will  quickly 
disappear. 

Treatment. — The  usual  treatment  of  such  cysts  is  incision  and  drainage, 
after  which  tliev  are  liable  to  recur.     It  is  better,  therefore,  to  dissect  awav  the 


494 


CYSTS    OF    TllK    KIDNKY 


cyst  wall  in  cases  in  wliich  adhesions  are  not  too  great,  or  else  to  l)ring-  the  in- 
cised sac  out  of  the  wound.  To  do  the  latter,  insert  a  catheter  in  it  and  inject 
with  tincture  of  iodin  or  some  other  iluid  to  cause  an  adhesive  inflanunation  be- 
tween its  walls.  Resection  of  that  part  of  the  kidney  from  which  the  cyst 
originates  (jxirtial  nephrectomy)  has  been  successfully  performed  Ly  D'Antona, 
Recamier  and  Albarran  in  five  cases,  but  does  not  appeal  to  nio  as  a  desira1)le 
procedure.  Nephrectomy  is  justified  in  cases  in  which  the  kidney  is  exten- 
sively destroyed  as  it  frequently  is  through  pressure  of  the  cyst.  The  cystic 
kidney  (Fig.  299)  was  removed  at  operation. 

(3)  Agglomerate  Cysts  (Polycystic  Kidney). — The  whole  kidney  may  be 
involved  by  a  conglomeration  of  cysts.     They  may  be  congenital  or  may  develop 


Fig.  300.  Two  Large  Polycystic  Kidneys  in  the  Same  Individual.  The  larger  kidney  was  10  by 
5}4  inches,  weight  56  ounces  ;  the  smaller,  9M  by  5  inches,  weight  48  ounces.  Removed  at  autopsy 
by  P.  F.  O'Hanlon.     (City  Hospital  case.     Author's  collection.) 


in  adults.  The  condition  is  almost  always  bilateral.  The  kidney  may  attain 
an  enormous  size  and  may  resemble  a  bunch  of  grapes,  weighing  five  or  six 
pounds  or  more.  The  cysts  are  translucent,  opalescent,  thin-walled,  of  the  size 
of  a  grape  or  smaller  and  some  are  tinged  with  red,  brown  or  green.     They  may 


ACCLOMERATE    CYSTS 


495 


be  packed  closely,  commimicating  with  one  anotlier  or  they  may  he  separated 
by  septa  of  fibrous  or  renal  tissue.  They  are  filled  with  a  clear  fluid  of  a  gelat- 
inons  consistence,  containing  crystals  of  cholestorin,  lonr-in,  nlbniiiin,  iirca  and 
phosphates  (Figs.  300  and  301). 


Fig.  301. — The  Larger  Kidney  in  Fig.  300,  on  Section.     (Author's  collection.) 

Causes. — Numerous  theories  have  been  advanced  as  to  the  mode  of  forma- 
tion of  these  cysts,  but  the  disease  seems  to  be  of  the  same  origin  in  infants 
and  in  adults.  Virchow  believed  that  this  degeneration  was  due  to  a  stenosis 
of  the  papilliL'  occurring  in  the  fetus  as  the  result  of  intra-uterine  nephritis, 
while  others  believe  that  the  disease  is  a  true  jtrocess  of  new  growtli,  i.  c.,  that 
there  is  first  an  adenoma  and  that  later  this  tumor  degenerates  into  cysts.  Fi- 
nally, some  authors  believe  that  the  cystic  degeneration  of  the  kidney  is  due  to 
congenital  nuilformation,  consisting  in  a  nonunion  of  the  excretory  and  the 
convoluted  tubules. 

Symptoms. — The  symptoms  are  those  of  chronic  nephritis.  There  are  oc- 
casionally pains  in  the  kidneys,  and  these  organs  are  found  enlarged  on  both 
sides.     The  pain  is  a  vague  one  with  a  sense  of  weight  in  the  hun  which  rarely 


496  CYSTS    OF    THE    KIDXEY 

becomes  acute,  colicky.  Althonoli  tlio  iioncral  shape  of  the  organ  is  maintained, 
the  irregular  outline  of  the  cysts  can  jjlainly  he  felt  in  thin  subjects,  the  cysts 
appearing  to  the  touch  like  an  irregular,  embossed  padding  of  the  kidney. 
There  is  usually  polyuria  and  low  specific  gravity,  diminished  urea,  all)umin 
and  sometimes  blood  in  the  urine. 

As  the  disease  progresses  and  the  excretory  function  of  the  kidney  dimin- 
ishes, the  patient  generally  begins  to  show  uremic  symptoms  and  the  course  of 
the  disease  becomes  the  same  as  that  of  any  nephritis  where  renal  function  is 
impaired.  The  patient  may  live  for  years  with  gradually  degenerating  kidneys. 
The  dangers  threatening  such  patients  are  anuria  and  the  infection  of  the  cystic 
kidney. 

Diagnosis. — Agglomerate  cysts  of  the  kidney  may  be  confounded  with  a 
malignant  tumor,  but  such  tumors  are  rarely  bilateral  and  puncture  would  fail 
to  produce  any  fluid.  The  condition  is  sometimes  mistaken  for  hydronephrosis, 
but  this  is  also  usually  unilateral  and  does  not  contain  a  fluid  with  so  much 
albumin  or  colloid  material  as  determined  by  ureteral  catheterization,  besides 
which  the  wall  of  a  hydronephrotic  kidney  is  smooth. 

Treatment. — The  treatment  is  symptomatic  and  otherwise  the  same  as  in 
a  case  of  chronic  nephritis,  the  aim  being  not  to  bring  any  undue  strain  upon 
incapacitated  kidneys.  Operative  interference  is  not  called  for  and  the  removal 
of  one  of  the  kidneys  would  be  unwise  and  would  simply  lessen  the  already  de- 
ficient area  of  secreting  renal  substance  by  at  least  fifty  per  cent.  Anuria  and 
death  would  be  likely  to  follow^  under  these  conditions,  as  the  opposite  organ  is 
usually  in  about  the  same  stage  of  degeneration. 

Sieber  collected  sixty-one  cases  of  cystic  kidney  in  adults,  where  nephrec- 
tomy was  performed  with  a  known  outcome,  including  twenty  deaths.  Fully  one 
half  of  the  patients  died  from  uremia  or  anuria,  on  account  of  simultaneous 
•cystic  degeneration  of  the  other  kidney.  The  only  excuse,  then,  for  nephrec- 
tomy in  a  cystic  kidney  would  be  the  occurrence  of  suppuration  or  malignancy 
in  one  of  the  organs.  If  the  diagnosis  is  uncertain,  an  exploratory  incision 
may  be  performed,  but,  on  finding  the  kidney  cystic,  it  should  1)e  left  alone 
unless  movalde,  in  which  case  it  can  be  fixed  in  place. 

(4)  Hydatid  Cysts. — Hydatid  cysts  of  the  kidney  are  rare  and  according 
to  Houzel  there  were  but  115  cases  in  2,111  of  echinococcus  disease.  The  left 
kidney  is  more  often  affected  than  the  right.  The  cyst  is  rounded,  elastic,  situ- 
ated deeply  in  the  kidney  or  projecting  from  its  surface.  Hydatid  cysts  may 
be  single  or  multiple  and  may  finally  destroy  the  whole  kidney. 

In  hydatid  cysts  of  the  kidney  there  is  usually  very  little  acute  pain,  al- 
though sometimes  it  is  most  distressing,  but  generally  a  dull  dragging  feeling. 
The  kidney  is  enlarged  and  can  usually  be  outlined  in  the  lumbar  region.  The 
cyst  frequently  bursts  into  the  pelvis  of  the  kidney  when  the  characteristic 
hydatid  substances  and  booklets  are  found  in  the  urine.     In  such  cases,  the  cystic 


HYDATID    CYST8 


497 


cavity  may  Iw'coiuc  infected,  ,i!,i\-iiiii'  rise  1(»  ;i  pyouepln-osis  ami  I  lie  enii-c(|iieiil 
syiiiptoins  of  a  renal  infect  i<iii.  Hydatid  cysts  ai-e  rarely  (■(mfoimded  wilji  solid 
tninors  of  the  kidney,  although  they  may  he  mistaken  ioi-  certain  patladogieal 
Condi ti(ms  of  the  organ. 

Hydronephrosis  may  be  distinguished  by  ureteral  catheterization,  and  aspi- 
ration will  differentiate  hydatid  from  other  renal  cysts  through  tlie  lluid  con- 
taining the  characteristic  booklets. 

Aspiration  is  not  advisable  for  diagnostic  purposes  in  renal  cases  unless  the 
kidney  has  first  been  exposed  by  a  lumbar  incision. 


Fig.  302. — Hydatid  Cyst  of  the  Kidney. 
The  organ  was  stretched  out  by  the  cyst  and  was  8  inches  long.      (Author's  case.) 

Treatment. — The  cyst  should  be  evacuated,  and  as  much  as  possible  of  the 
cyst  wall  should  be  cut  away  and  the  free  edges  sewn  into  the  abdominal  wound. 

Sometimes  all  the  cyst  wall  can  be  cut  away,  excepting  the  part  in  or  on 
the  kidney,  in  which  case  that  jjortion  of  the  wall  can  be  treated  by  an  applica- 


498  CYSTS    OF    THE    KIDNF.Y 

tion  of  pure  carbolic  acid  fulluwed  by  alcohol  which  ^vill  destroy  the  secreting 
cyst  surface  and  not  injure  the  kidney  tissue.  I  have  operated  on  one  of  these 
eases  which  was  treated  in  this  way  (Fig.  302). 

The  patient  was  a  liousewife,  aged  twenty.  Three  years  ago  she  had  an 
attack  of  severe  pain  in  the  right  lumbar  region  and  groin,  lasting  for  three 
days,  during  which  time  there  Avas  hematuria.  One  month  ago  she  had  an 
attack  of  very  acute  pain  in  the  same  locality.  Ilcr  urine  was  bloody  and  was 
voided  with  difficulty.  The  severity  of  the  pain  gradually  diminished,  but 
there  has  remained  more  or  less  pain  on  that  side  since  the  attack.  On  the  first 
visit  her  temperature  was  98.4°  to  100°  F.,  pulse  02  to  130.  The  right  kidney 
was  enlarged  and  tender,  extending  over  to  the  median  line.  Cystoscopy  showed 
the  bladder  to  be  normal.  The  ureters  were  catheterized.  The  urine  from  the 
left  side  was  secreted  normally,  and  was  found  normal  on  examination.  The 
urine  from  the  right  side  flowed  more  slowly,  was  very  pale  and  contained  a 
trace  of  albumin,  a  few  blood  and  pus  cells,  a  few  hyaline  casts,  renal  epithelia, 
uric  acid  and  triple-phosphate  crystals.  JSTo  exact  conclusion  was  arrived  at 
regarding  the  case,  and  an  exploratory  incision  Avas  made.  The  kidney  was 
found  to  be  very  much  enlarged ;  the  upper  pole  was  enlarged  and  adherent  to 
the  diaphragm,  the  lower  pole  was  smaller  and  twisted,  A  cyst  with  a  thick 
white  sac,  three  and  a  half  inches  in  length  and  two  and  a  half  in  width, 
was  seen  springing  from  the  anterior  surface  of  the  kidney  and  the  pelvis.  This 
was  opened,  and  a  considerable  amount  of  amber  fluid  and  a  number  of  small 
white  daughter  cysts  escaped.  The  outer  surface  of  the  sac  was  dissected  away, 
and  the  remainder  treated  with  carbolic  acid  and  alcohol.  During  the  first 
week  after  the  operation,  the  temperature  ranged  from  100°  to  104°  F.,  pulse 
136,  due  to  ether  pneumonia,  then  went  to-normal,  and  the  patient  left  the  hos- 
pital with  the  wound  healed. 


CHAPTER    XXVIII 
NEPHROLITHIASIS 

XEniROLiTiTTASTs  moaiis  stone  in  the  kidney.  All  these  stones  are  origi- 
nally of  a  small  size,  hut  on  account  of  certain  conditions  nnder  which  they  form 
in  the  kidney,  or  on  acconnt  of  the  locality,  some  remain  in  the  organ,  while 
others  are  washed  down  the  nrinary  tract  and  are  voided  in  the  urine.  Al- 
thongli  this  chapter  treats  of  stone  in  the  kidney  proper,  it  will  also  discnss 
stone  in  its  passage  throngh  the  nreter,  giving  rise  to  renal  colic  and  anuria. 

Etiology.- — Renal  calculns  occurs  more  frequently  in  males  than  in  females, 
and  nu^y  be  found  at  any  age.  Statistics  show  that  there  are  certain  periods  of 
life  during  which  stone  is  most  frequently  noticed,  especially  between  the  ages 
of  tAventy  to  fifty.  The  order  of  frequency  is  first  between  twenty  and  thirty ; 
second,  between  thirty  and  forty ;  third,  between  forty  and  fifty ;  fourth,  between 
fifteen  and  twenty ;  fifth,  between  fifty  and  sixty.  In  children  the  condition  is 
comparatively  rare.  Uric-acid  infarcts  have,  however,  been  found  in  the  new- 
born, and  it  is  therefore  possible  that  the  calculus  may  begin  to  form  at  a  very 
early  age.  During  my  service  in  the  St.  John  Guild  Hospital  for  children,  I 
did  not  have  a  single  case  of  renal  calculus ;  and  but  one  case  came  under  obser- 
vation in  the  children's  wards  of  the  (\)lumbus  Hospital  in  fifteen  years,  not- 
withstanding the  fact  that  nearly  all  these  children  were  Italians,  among  whom 
urinary  calculus  is  very  frequent. 

Country  and  race  have  some  influence  on  the  development  of  stone.  Warm 
countries  seem  to  favor  it  as  is  shown  by  the  frequency  of  renal  calcidiis  in 
India.  This  depends  greatly  upon  the  concentration  of  the  urine  due  to  the 
active  elimination  of  water  through  the  skin. 

Xephrolithiasis  is  said  to  be  more  frequent  among  the  Anglo-Saxons  than 
the  Latin  races.  I  thiid^,  however,  that  such  conclusions  are  due  to  the  fact 
that  better  statistics  and  more  com])lete  records  on  this  subject  have  been  pub- 
lished in  the  Anglo-Saxon  countries  than  elsewhere.  Personally,  I  have  found 
calculus  more  common  in  this  country  among  the  Italians  than  any  other  race, 
and  the  history  of  medicine  shows  that  in  the  past  more  provisions  were  made 
for  the  relief  of  stone  in  the  urinary  tract  in  Italy  than  in  any  other  country. 
In  the  [Tnited  States,  renal  calculus  is  comparatively  rare,  among  the  native-born 
Americans. 

499 


500  NEPHROLITHIASIS 

The  l'iiniiati<in  *A'  cnloilus  is  also  fax'orc*!  liy  (jvcrcating;,  especially  nitrog- 
enous and  ear])oliy<li-at('  f Is  in  excess,  as  well  as  by  the  free  nse  of  wines, 

beers  and  liquors,  in  people  who  take  but  little  exercise  and  therefore  consume 
an  insufficient  amount  of  oxygen.  Heredity  and  constitutional  factors,  such  as 
urieacidemia,  oxaluria  and  phosphaturia,  are  also  predisposing  factors.  A  mov- 
able kidney  sometimes  predisposes  to  the  formation  of  stones. 

The  immediate  cause  of  renal  calculus  is  the  deposit  of  the  crystals  in  the 
urine  upon  some  object  in  a  tubule  of  the  kidney,  or  in  its  pelvis,  that  will  act 
as  a  nucleus.  It  usually  takes  place  in  the  pelvis  or  one  of  its  calices,  and  is 
rare  in  a  renal  tubule.  Among  the  objects  that  have  been  found  in  the  central 
parts  of  calculi  and  npon  which  the  crystals  have  been  deposited  are  foreign 
bodies,  blood  clots,  masses  of  mucus  or  pus,  microorganisms  and  parasites. 

Foreign  bodies  usually  enter  the  kidney  through  traumatism,  such  as  a  bul- 
let, a  fragment  of  bone,  or  a  piece  of  the  clothing;  or  surgically,  in  the  form  of 
ligatures,  sutures,  or  gauze  used  during  an  operation.  At  present,  it  is  also 
possible  that  a  nucleus  may  occur  from  the  breaking  oif  of  the  end  of  a  ureteral 
catheter.  Blood  clots  may  be  due  to  any  variety  of  traumatism,  or  to  any  form 
of  renal  hematuria.     (See  chapter  on  Hematuria.) 

The  presence  of  mucus  in  the  renal  tubules  or  pelvis  may  be  due  to  any 
cause  of  a  sufficiently  irritative  character  to  produce  congestion,  followed  by 
destruction  of  the  epithelia,  sucli  as  crystals  in  the  urine ;  certain  drugs,  like 
cantharides ;  or  certain  pathological  products  excreted  in  the  urine  during  in- 
fectious diseases.  Pus  is  present  in  the  renal  pelvis  in  all  inflammatory  condi- 
tions, due  to  pus-producing  microorganisms,  and  can  therefore  frequently  serve 
as  a  nucleus  for  a  renal  stone. 

Regarding  the  part  that  parasites  and  bacteria  play  in  forming  the  nueler.s 
of  a  calculus,  opinions  differ.  Bilharzia  hematobia  has  been  found  in  the 
central  portions  of  calculi.  Bacteria  have  been  reported  in  calculi  by  Gallippe, 
Doyen  and  Fullerton,  Ijut  it  has  not  been  generally  accepted  that  they  act  as  a 
nucleus.  I  can  only  say  tliat  I  believe  it  to  be  usually  blood,  pus  or  mucus, 
singly  or  combined,  and  that  these  act  as  the  cement  so  often  spoken  of  as  a 
necessity  to  hold  the  urinary  crystals  together. 

Varieties. — Two  varieties  of  stone  are  the  jirimanj  and  secondary.  The  pri- 
mary stones  are  formed  by  the  precipitation  of  sul)stances  excreted  by  the 
kidney  without  any  previous  change  in  the  parenchyma,  the  pelvis  or  the  cal- 
ices. Secondary  stones  are  the  result  of  pathological  processes  in  these  localities, 
and  are  formed  when  certain  salts  are  precipitated  owing  to  the  decomposition 
of  the  urine.  Of  course,  a  calculus  may  be  originally  primary,  and  by  its  pres- 
ence so  irritate  the  surrounding  tissues  that  lesions  develoji  which  give  rise  to 
secondary  calculous  dejiosits  over  the  primary  calculus. 

Of  the  primary  variety  of  calculi,  we  have  those  formed  in  acid  or  in  alka- 
line urine.     The  varieties  develojDing  in  acid  urine  consist  of  one  or  more  of 


OCCURKENCE 


501 


tlie  following  siiLstances:  Uric  acid,  uratos,  calcimn  oxalates,  cvstin  and  xan- 
thin.  Tliose  formed  from  alkaline  urine  consist  of  calcium  carbonate,  acid 
phospliatcs  of  calcium,  or  basic  phosphates  of  calcium. 

Secondary  calculi  are  i)recii)itated  from  alkaline  urine  rendered  so  In-  aui- 
moniacal  decomposition,  due  to  some  local  infection  or  inflammation.  They 
consist  of  pliospJialcs,  either  of  ammonium  or  of  magnesium,  or  oi  both  am- 
nioniuui  and  magnesium. 

Occurrence. — The  frequency  with  which  the  various  calculi  occur  differs 
according  to  locality.  Oxalate  of  calcium  calculus  is  said  to  occur  more  fre- 
(juently  in  Great  Britain  than  either  the  uric  acid  or  the  phosphatic  variety  and 
produces  the  worst  cases  of  ne])hrolithiasis.  In  France  and  most  of  the  Latin 
countries  as  well  as  the  United  States,  the  uric-acid  variety  is  more  prevalent. 


Fig.  308. — Some  L.arge  fALcuLi  Removed  from  a  Pyonephrotic  Kidney.  The  largest  diameter  of 
these  ealeuli  wa,s  4,  2'^,  1^,  IJ^,  and  1^4  inches,  respectively.  In  the  reproduction  they  are  about 
three  quarters  of  their  actual  size.     (Author's  case.) 


The  number  of  calculi  in  a  kidney  varies  from  one  to  over  two  hundred,  and 
is  greater  in  suppurative  conditions  of  the  organ.  In  size  they  vary  from  grains 
of  sand  to  masses  weighing  five  pounds.  Uric-acid  stones  with  secondary  de- 
posits are  usually  the  largest,  while  oxalic  calculi  rarely  exceed  the  size  of  a 
nut.  Fig.  303  shows  some  large-sized  calculi  removed  from  a  case  of  pyo- 
nephrosis. 


502  NEPHROLITHIASIS 

Stones  are  more  often  fonnd  in  tlic  riiilit  kidney  than  in  the  left,  proLalily 
Ix'canse  it  is  more  frcqnently  moval)le,  \vliile  tlie  freqnency  of  stones  occurring 
in  l)()tli  kidneys  is  N'ariously  estimated  at  from  tive  to  fifty  per  cent.  From 
niy  own  ul)servatiniis  I  l)elie\'e  that  from  live  to  ten  per  cent  is  a  liheral 
estimate  of  the  occurrence  of  bihiteral  nephrolithiasis  as  it  occurs  in  this 
country. 

Pathology. — Primary  calculi  may  give  rise  to  aseptic  or  septic  changes. 
They  irritate  the  pelvis  of  the  kidney,  causing  congestion  and  later  fibrous  thick- 
ening of  its  ^vall,  an  aseptic  pyelitis,  followed  by  secondary  nephritis  of  an 
aseptic  type.  In  this  combined  aseptic  pyelo-nephritis,  the  inflammatory 
process  begins  in  the  renal  parenchyma,  later  involving  the  interstitial  frame- 
■^vork  of  the  organ.  It  is  always  present  in  calculous  kidneys,  and  other  lesions 
may  become  associated  with  the  nephritis  when  the  stones  have  reached  a  con- 
siderable size  and  have  remained  in  the  organ  for  a  long  time,  especially  if  they 
cause  obstruction  of  the  ureter.  The  first  of  these  secondary  lesions  is  renal 
atrophy.  Sometimes  the  perirenal  fat  is  increased  sufficiently  to  form  a  large 
lipomatous  tumor  containing  the  atrophied  kidney,  while  in  other  cases  the 
mechauical  obstruction  by  the  stone  gives  rise  to  hydronephrosis. 

The  septic  lesions  of  primary  calculi  are  secondary  to  the  aseptic  changes. 
The  infection  reaches  the  kidney  by  the  hematogenous  or  the  lymphogenous 
route,  or  ascends  directly  from  the  bladder.  The  predisposing  factors  of  septic 
infection  which  exist  in  calculous  kidney,  are  the  traumatic  effects  of  the  stones, 
the  urinary  retention  which  they  may  give  rise  to  and  the  capillary  congestion 
of  the  organ. 

The  results  of  infection  in  calculous  kidneys  are  pyelitis,  pyelo-nephritis, 
pyonephrosis  and  perinephritis. 

The  lesions  of  septic  pyelitis  are  the  same  as  those  of  the  aseptic  type  plus 
the  presence  of  pus.  Septic  pyelo-nephritis  results  when  the  infection  has 
involved  the  parenchyma  as  well  as  the  pelvis  of  the  organ,  in  wdiich  case  abscess 
formation  frequently  occurs.  It  has  been  noticed,  however,  that  when  the 
sclerotic  process  that  is  present  in  aseptic  pyelo-nephritis  is  sufficiently  ad- 
vanced, the  kidney  itself  seems  better  able  to  resist  the  invasion  of  bacteria. 
In  twenty-seven  per  cent  of  my  series  of  cases,  pyelo-nephritis  was  present. 
Pyonephrosis  takes  place  when  the  calculous  obstruction  has  been  sufficient  to 
cause  retention  of  urine  in  the  pelvis  of  the  kidney,  giving  rise  to  pelvic  dilata- 
tion plus  infection — Fig.  SO-t  shoAvs  a  case  of  acute  renal  retention  and  pyo- 
nephrosis ;  also  wdien  the  calculi  have  themselves  increased  in  size  to  such  an 
extent  as  to  press  upon  the  parenchyma  of  the  organ,  and  form  cavities  (Fig. 
305)  ;  or  wdien  the  parenchyma  has  been  destroyed  by  abscesses  in  pyelo- 
nephritis and  cavities  remain  communicating  with  the  pelvis.  Pyonephrosis 
occurred  in  seventeen  per  cent  of  the  cases  that  I  have  observed.  In  these, 
the  fatty  caj)sule  was  often  thickened  and  the  seat  of  fibrous  changes. 


PATHOLOGY 


503 


In  p_yelo-nepliritis  and  pyonephrosis,  a  true  perincpliritis  may  rlovolop  and 
adhesions  may  l)iiid  the  ki(hicy  to  the  surroiniding  oi'gans,  a  fact  of  im})ortancG 
to  be  remend)ei"C(l  wlien  ojierating  in  snch  cases,  as  they  may  involve  the  duo- 
denum, colon  and  even  the  vena  cava.  In  case  the  capsule  of  the  kidney  rup- 
tures, the  pus  may  burrow  in  any  direction,  making  a  true  perinephritic 
abscess.  I  have  had  quite  a  number  of  such  cases,  that  I  have  already  discussed 
in  the  chapter  on  Suppurative  Diseases  of  the  Kidney. 


Fig.  304. — A  Ptonephrotic  Kidney  in  a  State  of  Acute  Renal  Retention  of  XTrtne.  A  calculus 
is  seen  caught  in  the  beginning  of  the  ureter.  The  size  of  the  kidney  is  9  by  5H  inches.  (Author's 
case.) 


The  opposite  kidney  often  becomes  the  seat  of  compensatory  hypertrophy, 
in  its  effort  to  make  up  for  the  loss  of  functionating  tissue  in  the  diseased  organ, 
due  to  the  atrophic  changes  in  its  parenchyma  or  to  suppurative  processes.  A 
secondary  nephritis  usually  follows,  not  only  on  account  of  the  extra  amount  of 
work  that  is  thrown  upon  the  organ,  but  also  on  account  of  the  irritation  from 
the  acid  urates,  oxalates  and  phosphates  it  is  obliged  to  eliminate.  Calculi  may 
also  form  in  the  second  kidney.  It  is  likewise  more  prone  to  secondary  in- 
fection. 


504 


NEPHROLITHIASIS 


Symptoms  and  Diagnosis. — In  considering  nephrolithiasis,  wc  must  Lear  in 
mind  that  most  ])aticiits  have  active  subjective  symptoms,  but  there  are  many  in 
whom  these  are  absent.  In  these  cases,  tlie  stone  remains  in  the  kidney  in  such  a 
position  that  it  does  not  cause  irritation  or  attacks  of  urinary  retention.  Bruce 
Chirk  found,  in  l->  of  2-1  autopsies  on  persons  in  whose  ki(hieys  calculi  were 
])rcscnt,  that  there  had  been  no  symptoms  whatever  during-  life  referal)h'  to 


Fig.  305. — The  Renal  Pei-vis  of  a  Pyonephrotic  Kidney  Filled  with  Five  Stones  of  Large 
Size.  There  was  also  an  attack  of  acute  renal  retention  present  in  this  case,  and  the  affected  kid- 
ney contained  over  a  pint  of  pus. 

nephrolithiasis.  I  wish,  therefore,  to  emphasize,  at  the  beginning  of  the  clinical 
part,  that  the  symptoms  are  not  always  in  proportion  to  the  extent  of  the  dis- 
ease, and  that  I  have  often  been  surprised  to  find  how  few  subjective  symptoms 
a  patient  has  had  when  his  kidney  has  been  nearly  destroyed  by  a  calculus. 

In  some  cases,  the  existence  of  renal  stone  is  not  suspected  because  the  train 
of  symptoms  is  obscure,  or  for  the  reason  that  they  point  to  other  organs,  as  the 
bladder,  the  uterus,  the  ovaries,  the  testicles  or  to  the  gastro-intestinal  tract. 
In  the  majority  of  cases,  however,  the  subjective  symptoms  are  marked  and 
often  most  distressing. 

Pain. — Pain  occurs  in  most  cases,  and  is  situated  in  the  lumbar  region  cor- 
responding to  the  affected  side  or  in  that  side  of  the  abdomen.     This  had  been 


SYMPTOMS    AND   DIAGNOSIS  505 

])r('S('iil  ill  '.)2  per  cent,  of  my  ciises  for  a  ])erio(l  varyiiii;'  from  six  days  to  twenty- 
two  years,  with  an  averai^c  duration  of  four  years.  The  right  side  is  most  fre- 
quently aifec'ted,  and  in  my  own  eases  the  relative  frequency  was  G5  per  cent 
on  the  right  side  and  35  per  cent  on  the  left,  while  the  pain  was  bilateral  in 
l)ut  (I  per  cent.  The  abdominal  pain  may  run  down  to  the  groin  or  the  testis  on 
the  affected  side.  It  is  of  varying  degrees  of  intensity,  from  a  dull  ache 
to  the  excruciating,  sharp,  cutting  pain  of  renal  colic  It  may  be  continuous, 
l;ut  generally  follows  exercise  or  jolting,  although  cases  have  been  reported  when 
it  o(  (  urrcd  at  night. 

It  is  renal  colic  that  nsually  causes  the  patient  to  consult  a  physician,  espe- 
cially if  it  be  associated  with  or  followed  by  hematuria.  In  my  own  cases, 
thirty-three  ])er  cent  complained  of  this  symptom.  Attacks  of  colic  occur  when 
a  freely,  movable  stone  begins  to  engage  in  the  mouth  of  the  ureter,  or  to  descend 
along  the  canal.  The  forces  that  jDropel  a  stone  along  the  ureter  in  such  cases 
are  said  to  be  threefold,  viz. :  The  j^ressure  of  pent-up  nrine  behind  it,  the  forcible 
contraction  of  the  nreter  under  the  irritation  produced  by  a  foreign  body,  and 
the  alternating  })ositive  and  negative  pressure  of  the  act  of  vomiting  which  often 
accompanies  the  attack  of  colic. 

The  clinical  joicture  of  a  patient  in  the  throes  of  renal  colic  is  not  easily 
forgotten  when  once  seen.  The  facial  pallor,  the  cold  sweat,  the  flexed  thighs, 
the  bending  of  the  body  during  the  agony  of  the  paroxysm,  are  sufficiently  ty]ii- 
cal  to  direct  our  attention  to  the  probability  of  a  stone  in  the  pelvis  of  the  kid- 
ney or  passing  through  the  ureter.  The  pain  is  acute,  paroxysmal,  has  its 
chief  seat  in  the  loin  or  in  the  side  of  the  abdomen,  and  radiates  along  the  ureter 
toward  the  testicles  or  the  labia  majora,  or  into  the  thigh,  according  to  the 
course  of  the  spermatic  or  ovarian  plexuses  and  their  communications. 

The  access  of  pain  is  frequently  preceded- by  a  chill,  and  complicated  by 
attacks  of  nausea  and  vomiting.  The  j^aroxysm  usually  lasts  from  two  to  three 
hours,  and,  as  a  rule,  terminates  more  or  less  abruptly,  the  patient  feeling  re- 
lieved and  falling  asleep. 

In  milder  cases,  the  pains  are  not  so  colicky  or  paroxysmal,  and  consist  sim- 
ply of  slight  pricking  sensations  along  the  course  of  the  ureter,  accompanied  by  a 
feeling  of  slight  nausea. 

During  an  attack,  the  urine  may  be  passed  frequently.  It  may  be  clear,  of 
low  specific  gravity,  in  case  the  ureter  or  the  uretero-pelvic  opening  is  completely 
obstructed  by  the  calculus,  as  it  then  comes  from  the  healthy  kidney.  If  the 
ureter  is  not  completely  obstructed,  the  urine  may  be  tinged  with  blood ;  or  tur- 
bid, in  case  the  kidney  is  infected.  The  frequent  desire  to  urinate  depends 
upon  the  locality  of  the  calculus,  as  the  nearer  it  is  to  the  bladder,  the  greater  is 
the  frequency. 

Ureteral  blood  casts  are  sometimes  passed  in  the  urine  during  the  attack,  but 
usually  not  until  after  the  expulsion  of  the  calculus. 


506  XEPHROLITHIASIS 

The  cases  in  wliifli  the  stone  remains  in  the  kidney  or  pelvis,  withont  giving 
rise  to  attacks  of  renal  colic,  are  those  that  })resent  the  greatest  difficulties  in 
diagnosis.  Keflex  or  referred  pains  are  often  met  with  in  nephrolithiasis,  and 
frequently  mislead  the  diagnostician.  They  existed  in  twenty  per  cent  of  my 
cases  and  were  situated  principally  in  the  groin,  testicle  and  thigh.  In  such 
instances,  the  renal  region  may  be  free  from  pain.  The  pain  may  be  seated  in 
the  lumbar  sensory  nerves,  or  in  the  sciatic  nerve,  as  in  lumbar  sciatic  neuritis. 

The  reflex  pains  of  nephrolithiasis  have  been  classified  by  Guyon  as  follows: 
The  reno-renal,  reno-vesical,  reno-ovarian  or  reno-uterine  and  reno-testicular 
reflex. 

The  reno-renal  reflex  is  a  sensation  of  pain  in  the  kidney  that  is  not  sup- 
posed to  contain  a  stone,  and  is  attributed  to  its  reflex  transmission  from  the 
affected  side,  in  other  words,  from  one  renal  plexus  to  the  other.  Such  a  mani- 
festation is,  I  believe,  rare,  and  is  based  upon  the  idea  that  the  kidney  which  is 
not  thought  to  contain  the  stone  is  a  healthy  one.  Recent  investigation,  espe- 
cially since  the  development  of  ureteral  catheterization,  has  shown  that  this  other 
kidney  is  generally  not  a  normal  one,  in  fact,  that  it  is  usually  the  seat  of  a 
nephritis.  The  painful  symptoms  in  this  so-called  healthy  kidney  can  be  ac- 
counted for  in  various  ways.  The  healthy  organ  may  be  the  seat  of  an  occasional 
acute  congestion  when  an  extra  amount  of  work  is  suddenly  thro^vn  upon  it, 
owing  to  the  calculus  in  the  diseased  kidney  engaging  in  its  pelvis  and  thus 
interfering  with  its  function.  The  pain  may  also  be  more  acute  in  the  so-called 
healthy  organ  when  it  is  the  seat  of  an  inflammation  that  is  much  less  exten- 
sive than  that  of  the  other  organ  although  more  acute  in  character ;  again  when 
it  contains  a  stone,  not  identified  by  radiography,  which  is  rougher  and  conse- 
quently more  irritating;  or  when  there  is  a  stone  present  of  a  size  just  suffi- 
cient to  interfere  with  the  urinary  flow  and  to  cause  an  acute  distention  of  the 
pelvis.     The  reno-renal  reflex  occurred  in  six  per  cent  of  my  cases. 

Eegarding  the  reno-ureteral  reflex,  the  reno-ovarian  and  reno-testicular  re- 
flexes, I  will  say  that  such  pains  are  due  to  the  pressure  of  the  calculus  on  the 
sensory  nerve  fibers  of  the  spermatic  and  ovarian  plexuses  at  the  beginning  of  the 
ureter  in  the  pelvis,  or  lower  do^vn  in  case  it  is  descending  the  canal,  and  are 
consequently  distributed  to  the  organs  supplied  by  these  nerves. 

The  reno-vesical  reflex  can  be  explained  in  a  similar  way,  although  pain  in 
the  bladder  can  also  be  due  to  a  stone  in  the  part  of  the  ureter  that  is  contained 
in  the  bladder  wall. 

The  gastro-intestinal  reflex  is  a  more  genuine  reflex,  because  in  this  case  the 
pains  are  reflected  from  the  urinary  to  the  gastro-intestinal  tract  through  the 
connection  between  the  renal,  spermatic,  or  ovarian  plexuses  on  the  one  hand, 
and  the  gastric  or  splanchnic  plexuses  on  the  other.  This  probably  accounts  for 
the  large  number  of  patients  who  complain  of  dyspepsia,  by  which  name  they 
describe  an  unpleasant  feeling  in  any  part  of  the  abdomen,  such  as  can  be  pro- 


SYMPTOMS    AND    DIAGNOSIS  507 

diiccd  l)_v  an  iii(lii;csl  imi,  hv  i)i-ossnro  of  the  kidney  on  tlio  adjoining  organs,  or 
1)V  a  renal  ni-inary  i-clciil  ion.  The  wf>man  with  the  lai'gc  pyoncphrotic  kidney 
containing  nnnierous  calenli  (see  Fig.  o05)  complained  only  of  dyspepsia  and 
attacks  of  malaria. 

Hematuria. — If  the  reason  for  consulting  a  physician  for  this  disease  is 
not  pain,  then  it  is  nsually  the  presence  of  blood  in  the  urine.  This  is  one  of 
the  most  frequent  symptoms  of  renal  calculus,  and  was  complained  of  in  thirty- 
seven  per  cent  of  my  cases.  The  bleeding  in  these  cases  occurs  in  sufficient  quan- 
tity in  the  urine  to  be  detected  by  the  patient.  It  is  aggravated  by  movements 
and  by  prolonged  standing,  and  lessened  by  rest  in  bed.  It  is  due  both  to  conges- 
tiun  and.  to  injury  of  the  tissues  caused  by  friction  from  the  stone,  or  to  conges- 
tion of  the  wall  of  the  pelvis,  in  case  it  is  distended  by  a  stone  blocking  the 
ureteral  opening.  Oxalic  calculi  are  the  roughest  and  therefore  especially  liable 
to  cause  hematuria.  The  urine  and  blood  are  freely  mixed,  giving  the  color  of 
porter,  and  in  case  clots  are  present,  they  are  thin  and  elongated,  of  a  wormlike 
apj)earance  (ureteral  clots). 

I  have  seen  a  number  of  interesting  cases  of  hematuria  due  to  renal  stone, 
occurring  w^hile  playing  ball,  riding  horseback,  boxing  aftd  indulging  in  other 
athletic  sports.  Hematuria  in  such  cases  follows  pain  in  the  affected  side.  In 
the  case  of  a  grocer,  the  patient  stated  that  when,  in  his  w^ork,  he  lifted  objects 
from  the  ground,  especially  barrels  and  baskets  of  gToceries,  blood  would  appear 
in  his  urine.  I  had  him  come  to  my  office  for  a  cystoscopic  examination 
and  put  him  through  the  same  movements  with  pulley  weights  and  dumb-bells 
that  he  made  when  lifting  in  the  store,  to  see  if  hematuria  would  be  induced ; 
but  it  was  not,  showing  that  hematuria  cannot  be  brought  on  at  will,  or  else 
the  patient's  statements  are  not  always  truthful. 

Pyuria. — Pyuria,  strictly  speaking,  means  that  pus  can  be  detected  in  the 
urine  on  microscopical  examination;  but  clinically  it  means  there  is  a  sufficient 
amount  of  pus  to  make  the  urine  appear  opaque  or  turbid,  and  show  a  light 
precipitate  on  standing.  It  usually  occurs  in  the  course  of  nephrolithiasis, 
and  the  amount  may  be  so  abundant  as  to  form  twenty-five  per  cent  or  more 
of  the  urine  by  volume.  In  many  cases  the  urine  has  a  milky  color,  while  in 
others  it  resembles  lemonade.  Pyuria  occurred  in  over  fifty  per  cent  of  the  cases 
under  my  observation. 

General  Examination. — Palpation,  it  is  said,  will  in  certain  cases  reveal 
the  presence  of  stones,  if  they  are  of  sufficient  size.  This  nuiy  be  true,  and  I 
believe  that  a  kidney  that  can  be  sufficiently  well  palliated  to  detect  undue  hard- 
ness will  probably  prove  to  Ix'  either  a  calculous  kidney  or  a  nudignant  kidney. 
I  have  noticed  enlargement  of  the  organ  in  thirty-three  per  cent  of  the  cases  of 
renal  calculus  that  I  have  examined,  but  have  never  felt  the  stone.  It  is  often 
possible  to  determine  the  presence  of  tenderness,  the  degree  of  mobility  and  size 
of  the  organ  by  palpation,  which  are  important  points,  as  an  inflamed  kidney, 


508  NEPHROLITHIASIS 

especially  if  it  i-ontaiiis  a  foreign  body,  is  veiy  apl   to  \h_'  enlarged  and  tender 
and  Uriiily  attached  by  inflammatory  adhesions. 

The  kidney  is  tender  in  nearly  all  cases  in  wliicli  it  is  enlarged,  but  it 
cannot  always  be  outlined.  A  normal  kidney  cann(jt  usually  be  felt  and  is 
not  tender  to  the  tonch. 

There  are  other  symptoms  that  may  occur  in  nc]ilirolitliiasis  that  may  be 
mentioned  as  digestive  disturbance,  snch  as  nansea  and  vomiting,  abdominal  dis- 
tress and  poor  appetite.  These  are  nsnally  due  either  to  pressnre  or  dragging  on 
the  diiodennm  or  colon,  to  an  accompanying  nephritis,  or  to  a  septic  condition  in 
case  of  infection.  Headaches  are  probably  <lue  to  an  associated  nejihritis  or  sep- 
sis, as  are  Aveakness  and  loss  of  weight.  Edema  occasionally  occnrs  when  the 
renal  function  is  very  much  imj^aired. 

Fever  is  quite  common  in  nephrolithiasis  after  infection  has  taken  ])la'e. 
This  may  be  due  to  retention  of  ptis  in  the  pelvis  of  the  kidney,  after  the  stone 
has  engaged  in  the  ureter  in  pyonephrosis ;  or  to  a  pyelo-nephritis,  in  case  of  the 
presence  of  an  abscess  in  the  renal  parenchyma ;  or  to  a  complicating  perine- 
phritic  abscess.  It  is  usually  due  to  attacks  of  pyonephrosis,  in  Avhich  cases  the 
sym23toms  closely  resemble  malaria  and  are  accom})anied  by  chills  and  sweating, 
with  a  rapid  pulse. 

The  Ueixe. — The  examinatiou  of  the  urine  of  ])atients  suspected  of  nephro- 
lithiasis should  be  performed  by  a  skilled  pathologist  or  bacteriologist ;  the  prac- 
titioner should  not  be  satisfied  with  his  own  examination. 

The  amount  of  urine  is  usually  decreased.  The  reaction  is  generally  mark- 
edly acid,  except  in  cases  of  phosphatic  calculi  or  advancing  pyonephrosis; 
the  specific  gTavity  varies  with  the  amount  of  diluents  taken ;  the  color  may  be 
darker  than  normal  in  early  cases,  and  if  hematuria  be  present,  the  urine  has  a 
smoky-brown  or  portlike  color.  The  urine  shows  a  sediment  varying  in  color 
from  w^hite  to  dark  brown  or  red  ;  in  old  and  septic  cases  the  color  is  usually 
lighter,  due  to  the  absence  of  the  coloring  matter  and  solids  and  a  large  admix- 
ture of  pus.  The  examination  usually  shows  the  presence  of  albumin,  and  an 
excess  of  uric  acid  and  urates,  phosphates  or  oxalates,  as  the  case  may  be. 

Microscopical  findings  depend  upon  the  stage  of  irritation  or  inflammation 
of  the  kidney  and  consist  of  blood,  pus,  epithelium  from  the  tubules,  the  renal 
pelvis  or  the  ureter,  casts  (hyaline,  granular,  epithelial,  blood,  pus  or  mixed) 
and  bacteria.  Often  there  are  small  concretions  of  crystals  or  masses  of  crystal- 
line sediments,  such  as  calcium  oxalate,  triple  phosphates,  uric  acid  and  urates, 
pointing  to  the  nature  of  the  stone  in  the  organ. 

When  urine  of  this  kind  is  found  in  a  patient  suffering  from  pains  or  colic 
in  the  region  of  the  kidney,  the  pains  coming  usually  during  the  day  after  exer- 
cise, one  may  strongly  suspect  stone  in  the  kidney  on  the  side  on  which  the 
pain  is  felt,  especially  if  there  are  no  tubercle  bacilli  in  the  urine  or  any  signs  of 
tuberculosis  in  other  organs.    It  is,  therefore,  important  to  examine  the  bladder 


SYMPTOMS    AND   DIAGNOSIS  509 

by  cystoscopy  to  (Iclci'iniiic  ihc  coiiditiou  (»!'  its  walls,  the  ])rGSoiico  or  absence 
of  calculi,  and  to  note  the  urine  coming'  out  of  the  respective;  ureters.  Xaturally, 
this  refers  to  an  examination  not  occurring  at  the  time  of  renal  colic.  The 
bladder  wall,  in  case  no  vesical  calculi  are  present,  and  there  is  no  obstruction  to 
the  flow  of  urine  by  an  enlarged  prostate  or  stricture,  would  be  in  a  healthy 
condition.  In  case  of  renal  infection,  pus  would  be  seen  coming  from  the  ureter 
of  the  affected  side  indicating  the  presence  of  calculus  and  strengthening  the 
clinical  findings. 

It  may  be  well  to  say  a  few  words  regarding  the  difference  between  aseptic 
and  septic  nephrolithiasis.  They  differ  principally  as  to  the  presence  of  pus 
and  pus  casts.  If  we  are  confident  that  the  kidney  on  one  side  is  diseased  and  do 
not  know  the  condition  of  the  other,  we  can  feel  reasonably  sure  that  it  is  func- 
tionating well  if  it  is  not  enlarged  or  tender  and  if  the  twenty-four-hours'  urine 
is  of  sufficient  quantity  and  contains  the  desired  percentage  of  solids.  In  order 
to  be  more  certain  of  the  condition  of  the  two  organs,  we  should  examine  the 
urine  obtained  from  each  kidney  by  the  ureteral  catheter. 

The  urinary  specimens  obtained  by  ureferal  catheterization,  compared  with 
the  general  specimen,  usually  gives  us  a  good  idea  of  the  kidney  that  is  secreting 
the  good  urine  and  its  functionating  power,  as  well  as  the  degree  of  inflammation 
and  degeneration  of  the  affected  kidney.  The  appearance  of  the  urine  coming 
through  the  catheter  often  tells  us  something  of  the  pathological  condition  of  the 
kidney  on  that  side,  A  light-colored,  milky  urine,  of  low  specific  gravity,  is 
generally  a  mixture  of  water  and  pus  with  a  small  quantity  of  solids,  and  indi- 
cates pyonephrosis.  Urine  resembling  lemonade  generally  points  to  a  kidney 
secreting  a  considerable  amount  of  water  and  a  small  amount  of  solids,  and, 
if  it  contains  considerable  pus,  also  points  to  a  pyonephrosis.  In  pyonephrosis, 
a  thin  purulent  urine  of  low  specific  gravity  may  escape  quickly  on  the  intro- 
duction of  a  ureteral  catheter,  showing  the  pelvis  to  be  considerably  dilated. 
When  the  kidney  is  greatly  destroyed  and  secretes  but  little  fluid,  a  thick  and 
often  pure  pus  escapes.  In  one  case,  such  a  mass  resembled  closely  a  pebble 
in  the  bladder  hanging  from  the  ureter. 

By  the  urinary  examination,  cystoscopy,  catheterization  of  the  ureters  and 
cryoscopy,  we  would  know  that  a  practically  destroyed  septic  kidney  is  present 
on  the  side  from  which  the  pathological  urine  escapes,  and  that,  if  nephrolithi- 
asis is  present,  the  stone  is  on  the  septic  side, 

Radtography, — Radiogi-aphy  is  the  most  important  method  that  we  have  at 
present  for  determining  the  presence  of  renal  calculus,  although  it  cannot  always 
be  relied  upon,  as  we  often  see  a  shadow  in  kidney  pictures  in  cases  where  no 
stone  is  found  at  operation  ;  and  we  also  frequently  see  no  shadow  in  cases  in 
which  all  the  symptoms  point  to  stone  clinically,  and  in  which  an  operation  shows 
a  stone  to  be  present.  ISTevertheless,  when  a  clinical  diagnosis  of  stone  has  been 
nnide,  and  the  X-ray  finding  corroborates  it,  we  can  feel  quite  positive  that 


510 


NEPHROLITHIASIS 


nephrolithiasis  is  present.  The  X-ray  revealed  a  stone  in  seventeen  per  cent  (jf 
the  cases  I  ohserved,  l^nt  this  cannot  he  considered  accurate,  fV)r  a  number  Avero 
not  X-rayed  and  a  sliaddw  pointing-  to  stone  was  revealed   in  ccrlain  cases  in 


Fig.  306. — A  Cluster  of  Stones  in  One  Kidney.     The  position  of  these  .stones  was  found  to  have 
changed  in  the  different  radiographs  taken.      (Author's  case.) 


which  the  operation  proved  its  absence.  Radiography  not  only  shows  the  stones 
but  their  number  and  positions.  Fig.  306  shows  a  cluster  of  stones  in  the  kid- 
ney of  one  of  my  jjatients ;  Fig.  307  shows  a  cluster  in  each  kidney. 

Until  recently,  many  radiographists  claimed  that  uric-acid  stones  could  not 
be  seen,  and  some  still  believe  this  to  be  true,  although  the  majority  of  X-ray  ex- 
perts maintain  that  calculi  of  whatever  composition  can  be  detected  under  favor- 
able conditions. 

The  most  important  factor  in  obtaining  a  satisfactory  picture  is  to  have  the 
bowel  thoroughly  empty  when  the  patient  is  to  be  radiographed.  This  is  best 
obtained  by  giving  calomel  the  night  before,  followed  by  a  saline  aperient  in  the 
morning,  at  least  three  hours  before  the  radiograjdi  is  taken.  It  is  often  ad- 
visable to  have  a  patient  X-rayed  on  two  or  three  different  occasions  in  a  case 
in  which  the  clinical  findings  point  to  stone  and  the  X-ray  findings  are  negative. 


DIFFERENTIAL   DIAGNOSIS 


511 


The  exploraiory  incision  is  always  jnstifia])lo  in  a  case  of  chronic  suppurat- 
ing disease  of  one  kidney,  to  determine  whether  a  stone  is  present  in  the  kidney 
or  not.  If  one  is  found,  it  should  be  removed  and,  in  any  case,  the  pelvis  ex- 
plored and  drained.  It  would  seem  that  an  exploratory  nephrotomy  would  at 
once  establish  the  diagnosis,  but  I  will  show  by  a  case  that  I  will  mention  under 
treatment  (Fig.  30S)  that  this  nmy  fail,  even  when  one  feels  that  he  has 
been  careful  in  the  exjdoration. 

Differential  Diagnosis. — Stone  in  the  kidney  is  more  apt  to  be  confounded 
with  tuberculosis  or  tumor  of  that  organ  than  with  any  other  renal  disease. 
The  principal  jDoints  of  differentiation  lie  in  the  history.  In  favor  of  the  cal- 
culus there  may  be  the  presence  of  gout,  rheumatism  or  lithemia  in  the  indi- 


I 
I 


Fig.  307. — A  Cluster  of  Stones  in  Both  Kidneys.     (Erdnian's  case.) 

vidual  or  in  the  family,  while  tuberculosis  may  be  suggested  by  a  tid)erculous 
history  on  the  part  of  the  patient  or  the  family.  Tuberculosis  of  the  kidney 
usually  comes  on  more  rapidly  and  the  patient  is  more  cachectic ;  the  pain  and 
hematuria  occur  independently  of  exertion  and  often  take  ]ilace  at  night  as  well 
as  by  day,  Avhile,  in  cases  of  calculus,  these  symptoms  occur  almost  always  dur- 


512  XEPHROLITHIASIS 

iiig'  the  day.  In  renal  tvibereul(jsi.s,  there  may  be  an  involvement  of  the  genito- 
urinary tract  elsewhere,  as  in  the  bladder,  prostate  or  testis,  and  tubercle  bacilli 
will  sooner  or  later  be  found  in  the  urine,  or  after  guinea-pig  inoculation, 
whereas  radiography  would  be  negative. 

In  cases  of  tumor  of  the  kidney,  the  patient  is  usually  of  a  more  advanced 
age,  the  pain  is  not  as  great  and  occurs  independently  of  exertion.  The  malig- 
nancy of  the  growth  is  expressed  by  the  cachexia  and  loss  of  weight  which  ac- 
companies these  cases.  In  such  patients,  the  hemorrhages  are  much  more 
abundant  and  not  necessarily  associated  with  exercise,  moving  or  jolting.  The 
organ  is  usually  clearly  outlined ;  the  nrine  may  contain  characteristic  tumor 
fragments  or  cells,  and  is  not  apt  to  contain  crystals.  The  pain  is  always  in  the 
back  and  loins. 

A  movable  hidney  may  also  give  rise  to  a  dull  ache  in  this  region  or  even 
to  renal  colic  (Dietl's  crises)  ;  hematuria  is  rarely  present  or  is  slight,  pyuria 
rarely  develops  and  pyelitis,  pyelo-nephritis  and  pyonephrosis  are  only  excep- 
tionally associated  with  it.  The  mobility  can  be  discerned  on  examination,  it 
is  generally  not  as  large  as  a  calculous  kidney  and  the  signs  of  renal  destruction 
are  not  so  marked  in  the  nrine.  I  have  had  cases  of  movable  kidney,  however, 
in  which  stone  was  present,  requiring  the  double  operation  of  nephrolithotomy 
and  nephropexy. 

Bladder  diseases  caused  by  stone,  tuberculosis  or  tumor,  with  or  ^vithout  an 
associated  cystitis,  or  bladder  involvements  due  to  stricture,  prostatic  hyper- 
trophy or  gonorrhea  often  have  to  be  differentiated  from  nephrolithiasis.  In 
these  cases,  hematuria,  pyuria  or  both  may  be  present.  A  urethral  and  rectal 
examination,  associated  with  visual  exploration  of  the  bladder  by  means  of  an 
examining  cystoscope,  will  clear  up  the  diagiiosis,  by  showing  gonorrhea,  ure- 
teral stricture  or  prostatic  enlargement  on  the  one  hand ;  or  vesical  calculus, 
tumor,  or  vesical  tubercles  or  ulcers  on  the  other.  In  the  cases  of  nephrolithiasis 
that  I  have  studied,  cystitis  was  present  in  twenty-three  per  cent  of  the  cases, 
and  vesical  calculus  in  two  per  cent. 

Nephralgia  is  the  most  difficult  condition  to  diiferentiate  from  renal  cal- 
culus. It  is  characterized  by  a  pain  of  the  neuralgic  type  in  the  renal  region 
on  one  side,  which  can  be  accounted  for  by  any  surgical  condition  of  the  kidney 
as  well  as  by  a  nephritis.  The  only  method  of  arriving  at  a  diagnosis  is  by  ex- 
cluding all  pathological  conditions  in  the  kidney  that  can  give  rise  to  pain. 
This  is  often  impossible,  and  the  probabilities  are  that  many  of  the  cases  that 
are  considered  nephralgia  are  really  obscure  forms  of  nephrolithiasis. 

Certain  forms  of  nephritis  accompanied  by  pain  and  hematuria  closely  re- 
semble renal  calculus  by  the  attacks  of  pain  and  bleeding.  In  these  cases,  the 
urinary  crystals  and  the  signs  of  pyelitis  are  not  so  common,  the  signs  of  sup- 
puration are  rare,  the  kidney  is  not  enlarged  and  radiography  is  negative. 
iSTephrolithiasis  has  been  mistaken  for  malaria  in  many  patients  that  have  been 


TREATMEXT  51 3 

sent  to  me,  due  without  doubt  to  an  occasional  renal  retention  of  pus  when  the 
calculus  blocked  the  ureter  and  the  consequent  giving  rise  to  chills,  fever  and 
sweating.  A  number  of  other  abdominal  conditions,  such  as  cholelithiasis  and 
appendicitis,  have  been  confounded  with  renal  calculi.  Gall-stone  is  suggested 
by  a  history  of  gastro-intestinal  disturbances,  location  of  the  tenderness  in  front, 
the  pain  radiatiuii'  backward  and  upward  and  negative  findings  in  the  urine. 
It  is  practically  impossible,  at  times,  to  differentiate  between  cholelithiasis  and 
nephrolithiasis  when  the  patient  is  seen  in  an  acute  attack  of  colic. 

Appendicitis  can  also  be  at  times  mistaken  for  nephrolithiasis,  especially  in 
suppurative  cases,  with  or  without  renal  retention,  or  in  which  there  is  calculus 
in  that  part  of  the  ureter  passing  beneath  the  cecum  ;  for  in  such  cases,  we  will 
be  liable  to  have  pain  in  the  region  of  the  appendix.  In  one  case,  all  these 
symptoms  were  present  and  the  diag-nosis  of  the  house  surgeon  was  appendicitis. 
The  patient  was  brought  to  the  table  for  operation,  an  incision  was  made  over 
the  tumor,  the  appendix  Avas  found  to  be  slightly  congested  and  the  lower  pole 
of  the  kidney  was  found  to  be  crowded  up  beneath  the  cecum  and  appendix 
forming  a  distinct  tumor.  The  patient  had  consented  to  an  operation  for  ap- 
pendicitis, and  the  appendix  was  removed.  Upon  investigating  this  case,  I 
found  that  pus  had  been  found  in  the  urine  together  with  pus  casts.  The  case 
proved  to  be  one  of  pyonephrosis,  depending  on  a  renal  calculus,  which  was 
subsequently  removed. 

Treatment. — The  treatment  of  nephrolithiasis  is  both  medical  and  surgical. 
It  depends  upon  the  symptoms  of  the  patient,  and  the  aseptic  or  septic  nature 
of  the  case. 

Medical  Teeatmext. — The  medical  treatment  is  symptomatic  and  palli- 
ative. If  the  case  is  an  aseptic  one,  treatment  depends  upon  the  size  of  the  cal- 
culus. One  of  such  a  large  size  that  it  is  retained  in  the  kidney  and  cannot 
pass  through  the  ureter  is  treated  according  to  the  symptoms  that  it  presents. 

If  there  is  great  pain,  especially  in  the  nature  of  a  colic,  morphin  should 
be  given  imtil  the  pain  has  subsided.  When  an  attack  of  hematuria  occurs,  the 
patient  should  be  kept  quiet  and  Basham's  Mixture  (mistura  ferri  et  ammoni(P 
acetatis)  should  be  given  in  half-ounce  doses,  three  times  a  day.  In  ease  the 
hematuria  is  severe,  fifteen  drops  of  the  fluid  extract  of  ergot  and  fifteen  drops 
of  the  tincture  of  ehlorid  of  iron  should  be  given  every  three  hours  until  it  has 
subsided.  Personally,  I  have  never  as  yet  seen  a  case  of  renal  calculus  in  which 
the  hemorrhage  was  sufficiently  severe  to  warrant  the  use  of  ergot. 

Diet. — I  would  also  give  the  patient  a  diet  suitable  for  the  accompanying 
nephritis  (see  chapter  on  Xephritis),  and  would  recommend  operative  inter- 
ference. The  diet  in  nephrolithiasis  is  very  important.  For  the  associated 
nephritis  it  should  be  the  same  as  in  Bright's  disease,  but  it  should  be  modified 
according  to  the  crystals  found  in  the  urine.  If  oxalate  of  lime  is  present,  then 
the  diet  of  oxaluria  is  given ;  if  uric  acid,  then  the  diet  of  uricacidemia ;  if 


514  NEPHROLITHIASIS 

phosphates,  then  the  diet  of  phosphaturia.  (See  diets  in  the  chapter  on  Dis- 
eases of  Metabolism.)  During  an  attack  of  renal  colic,  a  milk  and  Vichy  diet 
should  be  given  in  all  cases. 

If  the  calculus  is  a  small  one  and  passes  into  the  ureter,  causing  colic  in  its 
passage  down  to  the  bladder,  I  would  also  give  sufficient  morpliin  to  alleviate 
the  pain.  After  it  has  passed  and  no  more  pain  is  present,  I  would  treat  the 
patient  on  prophylactic  or  preventative  lines ;  in  which  case,  I  would  give  the 
diet  indicated  by  the  crystals  found  on  urinary  examination,  such  as  one  for 
oxaluria,  uricaeidemia  or  phosphaturia.  Diluents  are  also  of  gi-eat  value.  For 
the  uric-acid  diathesis,  the  waters  of  Contrexeville  in  France,  of  Wildungen  in 
Germany  and  other  alkaline  diuretic  waters  should  be  given.  In  a  case  of 
oxaluria,  I  would  give  carbonated  alkaline  waters,  such  as  Apollinaris.  Bitter 
waters  containing  magnesia  have  also  been  recommended.  For  phosphaturia, 
an  acid  treatment  such  as  dilute  nitro-muriatic  acid,  fifteen  drops  three  times 
daily,  will  be  beneficial.  Phosphorus,  nux  vomica  and  arsenic  are  useful  medic- 
inal agents,  in  these  cases,  and  urotropin  wdien  bacteria  appear  in  the  urine. 

In  septic  cases,  the  treatment  is  the  same  as  in  aseptic  conditions  plus  the 
treatment  of  suppuration.  For  surface  suppuration,  such  as  occurs  in  the  pelvis 
of  the  kidney  and  in  the  larger  tubules  that  are  not  blocked,  as  well  as  in  cases 
in  which  there  is  some  retention  and  alkaline  decomposition  in  the  renal  pelvis, 
urotropin  ten  to  fifteen  grains  three  times  daily,  benzoic  acid,  or  some  other 
urinary  antiseptic,  should  be  given.  In  cases,  however,  in  which  there  is  acute 
suppuration  in  the  parenchyma  of  the  kidney,  such  as  occurs  in  pyelo-nephritis, 
or  an  acute  attack  of  retention  in  a  pyonephrotic  kidney  with  pus  absorption, 
quinin  and  whisky  should  be  given.  This  a23plies  also  to  a  perinephritic  abscess 
complicating  a  suppuration  of  the  kidney. 

In  other  words,  the  same  treatment  as  in  any  other  septic  case  is  followed, 
it  being  remembered,  however,  that  the  kidney  is  involved  and  consequently 
the  parenchyma  is  damaged  in  a  greater  or  less  degree.  In  my  opinion,  quinin 
and  alcoholics  are  the  best  general  remedies  for  fever  due  to  sepsis,  and  I  there- 
fore recommend  them  during  an  attack,  being  careful,  how^ever,  to  avoid  doses 
that  will  not  be  well  tolerated  by  these  organs.  I  am  in  the  habit  of  giving  three 
grains  of  quinin  three  times  a  day,  and  one  ounce  of  whisky  three  or  more  times 
a  day. 

Sometimes  it  is  difficult  to  differentiate  between  tuberculosis  of  the  kidney 
and  stone,  especially  when  radiography  is  negative.  In  the  event  of  the  diag- 
nosis being  doubtful,  and  wdien  it  is  a  question  whether  stone  or  tuberculosis  is 
present,  as  often  happens  when  the  X-ray  is  negative  and  tubercle  bacilli  are 
not  for.nd  in  the  urine,  I  give  the  patient  creosote  until  the  question  of  tr.lercu- 
losis  has  been  eliminated.     (See  chapter  on  Renal  Tuberculosis.) 

Opekative  Treatment. — This  is  the  radical  treatment  for  stone  in  the 
kidney  and  should  be  employed  in  all  cases  in  which  a  stone  is  retained  in  the 


TREATMENT  515 

organ,  or  in  which  one  passes  into  the  ureter  and  completely  blocks  it,  giving 
rise  to  a  hydronephrosis,  a  pyonephrosis  or  anuria,  in  which  last  instance  it  be- 
comes an  emergency  case. 

The  operations  employed  in  the  treatment  of  nephrolithiasis  are :  Pyelot- 
omy,  nephrotomy,  primary  neplirecjtomy,  secondary  neplirectomy  and  ureter- 
otomy. In  any  case  of  nephrolithiasis,  whether  symptoms  are  present  or  not, 
the  diagnosis  having  been  made,  the  stone  should  be  removed.  This  applies  to 
both  aseptic  and  septic  cases.  In  clean  cases  with  the  clinical  diagnosis  of 
stone,  not  confirmed  by  X-ray,  in  which  other  renal  conditions  have  been  ex- 
cluded, an  exploratory  nephrotomy  should  be  performed.  This  applies  also  to 
septic  cases,  and  should  not  be  postponed  in  case  the  patient  is  losing  weight  and 
strength. 

In  patients  suffering  from  nephrolithiasis,  we  may  say  that  if  the  function 
of  the  diseased  kidney  is  fair,  as  shown  by  examinations  of  specimens  of  urine 
obtained  by  ureteral  catheterization,  the  operation  should  be  nephrotomy ;  but 
in  case  the  two  specimens  show  that  the  function  of  the  diseased  kidney  is 
very  much  impaired  and  that  the  organ  is  a  pus  sac  of  no  value  and  injuring 
the  health  of  the  individual,  a  nephrectomy  should  be  performed,  provided  that 
the  other  kidney  has  sufficient  functionating  renal  tissue  to  excrete  urine  of  the 
required  amount  and  character.  When  there  is  a  question  of  doubt  before 
the  operation  is  performed,  whether  nephrectomy  or  nephrotomy  should  be 
done,  it  is  advisable  to  obtain  the  patient's  permission  to  do  whichever  is  con- 
sidered better  after  cutting  down  upon  and  examining  the  organ.  Sometimes 
we  operate  to  do  a  nephrotomy  and  find  that  the  kidney  is  so  damaged  that  it 
should  be  removed,  and  that  the  patient's  condition  is  such  that  a  nephrectomy 
could  easily  be  borne ;  but  we  do  not  feel  justified  in  removing  the  organ  after 
having  told  the  patient  that  the  operation  was  to  be  a  nephrotomy.  It  is  bet- 
ter, then,  having  obtained  the  patient's  consent  to  do  what  seems  to  us  to  be 
advisable,  to  remove  the  kidney  if,  upon  examining  it,  we  find  that  it  is  simply 
a  pus  sac.  In  such  a  case,  if  a  nephrotomy  were  performed  it  would  be  ex- 
tremely difficult  for  the  wound  to  heal  afterwards,  and  a  urinary  or  suppura- 
tive sinus  from  the  kidney  would  remain  that  would  injure  the  patient's  health 
and  reduce  the  resistance  to  such  a  degree  that  a  secondary  nephrectomy  would 
not  be  so  well  borne. 

After  the  kidney  has  been  delivered,  it  should  be  examined  bv  holding  it  in 
one  hand  and  palpating  it  carefully  with  the  fingers  of  the  other  over  its  entire 
surface.  The  ureter  should  then  be  palpated  and  the  forefinger  pushed  up 
along  the  ureter,  invaginating  into  the  hilum  wdth  the  object  of  palpating  the 
calicos. 

In  some  cases,  it  is  advisable  to  perform  pyeJotomy,  that  is,  to  make  a  small 
incision  in  the  posterior  wall  of  the  pelvis  parallel  with  the  course  of  the  ureter, 
in  order  that  the  calices  may  be  palpated  and  a  stone,  however  small,  detected. 


516  NEPHROLITHIASIS 

Very  little  hemorrhage  attends  such  an  operation,  and  a  small  stone,  if  present, 
can  easily  be  withdrawn  by  forceps. 

Xeedling  the  kidney  is  of  no  value  and  has  never  given  me  any  results.  This 
is  especially  unsatisfactory  in  cases  of  pyonephrosis  with  retention  of  pus. 
Sometimes  areas  of  induration  are  felt  in  a  kidney  that  closely  resemble 
stone,  l)ut  \\'liich  prove  on  opening  the  kidney  to  be  only  dense  nodules  of 
tissue. 

Aspiration  is  of  value  in  pyonephrotic  and  hydronephrotic  kidneys,  espe- 
cially if  the  ileo-costal  space  is  small,  as,  after  having  emptied  the  sac,  it  is 
easier  to  deliver  the  kidney  and  the  organ  can  also  be  more  thoroughly  pal- 
pated. It  is  also  of  value  in  case  a  nephrectomy  is  contemplated,  as  it  is  much 
easier  to  ligate  the  pedicle  after  withdrawing  the  retained  pus  and  urine  from 
the  kidney. 

If  aspiration  is  performed  in  these  cases,  it  is  well  to  connect  the  end  of 
the  cannula  with  a  soft-rubber  tube  and  allow  the  pus  to  escape  into  a  vessel  out- 
side of  the  operative  field.  The  cavity  can  then  be  washed  out  Avith  an  anti- 
septic solution  after  its  contents  have  been  withdrawn. 

This  method  of  visual  examination  and  palpation  of  the  kidney  after  its 
delivery,  together  with  the  urinary  analysis  already  made,  will  give  us  a  fair 
idea  of  whether  the  kidney  is  tolerably  healthy  or  extremely  diseased. 

Aspiration  of  the  kidney  does  not  interfere  with  any  operation  that  we  may 
be  called  upon  to  perform  later. 

Nephrotomy,  incising  the  kidney  through  the  parenchyma  into  its  pelvis  is, 
of  course,  the  operation  par  excellence  for  the  removal  of  stone  or  for  inspect- 
ing the  interior  of  the  kidney,  and  I  have  operated  thirty-one  cases  by  this 
method.  The  hemorrhage  is  often  quite  profuse,  thus  preventing  the  operator 
from  inspecting,  as  clearly  as  he  would  like,  the  pelvis  and  ealices,  notwith- 
standing the  fact  that  the  vessels  of  the  pedicle  are  compressed  by  an  assistant 
with  his  fingers,  by  padded  clamps  or  by  a  rubber  band. 

After  a  nephrotomy  in  clean  cases,  I  ha^'e  closed  the  kidney  and  the  abdomi- 
nal w^all  as  well,  without  drainage,  and  the  recovery  has  been  satisfactory.  It 
may  be  w^ell  to  say,  however,  that  recovery  from  operation  is  not  always  assured 
even  in  an  aseptic  case,  and  I  well  remember  one  case  which  I  considered  very 
promising  in  which  the  patient  died  very  quickly.  It  was  that  of  a  young  man, 
tall  and  athletic,  on  whom  I  operated  some  years  ago  and  closed  the  external 
wound  after  removing  the  stone  and  suturing  the  kidney,  but  the  patient  died 
of  uremia  and  sepsis  in  two  days,  notwithstanding  the  fact  that  the  woimd  was 
fully  opened  and  drained  on  the  following  morning  as  soon  as  serious  symptoms 
appeared. 

In  a  clean  case  of  nephrotomy,  the  kidney  should  be  closed  and  a  wick  or 
cigarette  drain  should  always  be  left  in  the  wound  from  the  convexity  of  the 
kidney  and  allowed  to  remain  for  twenty-four  hours,  when  it  can  be  removed  if 


TKEATMENT  517 

there  is  no  urinary  leakage;  but  in  case  the  urine  is  leaking  away,  the  drain 
shonld  remain  in  for  a  longer  period. 

In  cases  which  are  apparently  clean,  bnt  in  whose  urine  pus  has  been  found 
by  the  microscope,  the  kidney  should  be  drained  l)y  a  tube  in  its  pelvis  after 
nephrotomy. 

When  a  stone  is  removed  from  a  moval)le  kidney,  as  occasionally  happens, 
the  kidney  should  be  fixed  to  the  abdominal  wall  after  nephrotomy  has  been  per- 
formed. 

In  cases  of  pyelitis,  pyelo-nephritis  or  pyonephrosis,  there  ma}'  be  a  purulent 
discharge  from  the  kidney  through  a  sinus  in  the  loin  for  several  weeks,  or  per- 
haps several  months,  unless  further  operation  is  resorted  to.  In  favorable  cases, 
three  weeks  may  be  spoken  of  as  the  average  time  for  a  sinus  to  close,  whether 
it  be  urinary,  purulent  or  both.  Sometimes  a  sinus  will  close  and  the  patient 
will  have  an  elevation  of  temperature,  showing  that  pus  has  accumulated  outside 
of  the  kidney,  in  which  case  it  will  be  necessary  to  reopen  the  wound.  It  is, 
therefore,  important  to  put  a  drainage  tube  down  to  the  organ,  and  not  to  insert 
it  between  the  skin  and  the  muscular  walls.  In  one  case,  a  perinephritic  abscess 
develoi3ed,  the  pus  burrowing  along  the  ureter  and  forming  a  tumor  in  the  gi'oin, 
while  in  another  it  burrowed  down  below  Poupart's  ligament  and  had  to  be 
oj^ened  in  the  thigh. 

A  nephrotomy  does  not  always  reveal  the  stone.  In  one  case,  after  opening 
the  kidney,  carefully  examining  the  pelvis  and  exploring  it  with  a  probe,  I 
drained  the  organ  and  treated  it  as  usual ;  but  as  the  patient  continued  to  run  a 
septic  temperature  and  was  losing  ground,  I  performed  nephrectomy  and  dis- 
covered a  calculus  hidden  behind  a  dense  barrier  of  thick  fibrous  tissue,  in  a 
space  connecting  both  with  the  renal  pelvis  and  the  perirenal  space  by  sinuses. 
The  pelvis  had  been  palpated  and  probed,  without  success,  before  its  removal, 
but  afterwards  by  bending  the  probe  in  a  certain  direction  it  could  be  passed 
into  the  pocket  where  the  calculus  was  concealed  and  from  there  into  the  renal 
pelvis.  Fig.  308  shows  the  stone  lying  in  a  pouch  surrounded  by  a  dense  mass 
of  fibrous  tissue  held  to  one  side  by  a  hook. 

Nephrostomy,  that  is,  a  nephrotomy  plus  the  fastening  of  the  walls  of  the 
incised  kidney  to  those  of  the  abdominal  incision  is  sometimes  more  satisfac- 
tory, as  the  organ  can  be  better  drained  aud  the  dressing  of  the  renal  pelvis 
is  easier  than  when  the  organ  slips  up  under  the  ribs  as  it  usually  does  after 
ne])hrotomy.  In  ten  per  cent  of  the  eases  operated  on,  I  employed  this  method. 
While  drainage  is  better  during  the  after  treatment  by  this  means,  the  kidney 
remains  lower  down  than  normal  after  the  operation  and  later  on  the  ureteral 
drainage  into  the  bladder  may  not  be  so  good  as  if  the  organ  had  been  drained 
from  its  normal  position. 

Nephrectomy  or  removal  of  the  kidney,  can  be  ]ierfnrnied  in  cases  of  pyelo- 
nephritis with  numerous  abscesses,  or  in  cases  of  jn-onephrosis  in  which  the  "^ 


518 


NEPHROLITHIASIS 


organ  is  merely  a  pus  sac  containing  stones,  or  when  it  is  bnt  a  mass  o£ 
sclerosed  tissue.  I  performed  nephrectomy  in  twenty-one  per  cent  of  the 
cases. 

Secondary  nephrectomy  is  the  same  as  primary  nephrectom}"  unless  there 
are  very  dense  adhesions  present,  which  is  often  the  case  if  the  operation  is 
delayed  too  long  after  the  nephrotomy.  A  source  of  danger  in  pus  cases  is 
the  tearing  of  the  peritoneum  and  infection  of  its  cavity.  I  have  unfortunately 
torn  through  the  peritoneum  on  three  occasions,  in  two  of  which  I  sewed  up 
the  membrane  again,  and  in  the  other  walled  it  oft"  with  a  piece  of  gauze.  In 
none  of  the  cases  did  peritonitis  occur. 


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Fig.  308. — ^A  Calculus  Concealed  in  the  Thick  Mass  of  Fibrous  Tissue  Held  Open  by  the 
Hook  not  Detected  by  Nephrotomy.  The  kidney  was  in  a  state  of  pyonephrosis.  (Author's 
case.) 

Subcapsular  neplirectom^'  is  a  safer  operation  in  cases  in  which  both  the 
capsula  propria  and  the  fatty  capsule  are  thickened  and  adherent  and  the  leaflets 
of  the  perirenal  fascia  are  also  thickened ;  for  it  is  comparatively  easy  to  remove 
these  combined  capsules  from  the  kidney,  whereas  to  separate  them  from 
one  another  often  causes  a  considerable  prolongation  of  the  operation,  and  in- 
duces shock.  I  know  that  many  patients  Avho  are  in  a  weakened  condition  die 
from  the  extra  exposure  to  which  they  are  subjected  when  the  usual  nephrectomy 


TREATMENT 


519 


Fig.  309. — A  Renal  Calctjlus  that 
Was  Discharged  through  the 
Wall  of  the  Kidney,  Giving 
Rise  to  a  Perinephritic  Ab- 
scess.     (Author's  case.) 


is  locrformed,  whose  lives  might  have  been  saved  had  a  subcapsular  operation 
Leen  performed. 

Partial  nephrectomy  is  generally  a  dangerous  operation  and  ore  that  I  have 
performed  but  once.  In  this  case,  a  renal  calculus  had  ransod  a  ]-)yonephrosis 
with  a  destruction  of  the  kidney;  an  abscess  of 
the  organ  developed,  broke  and  discharged  out- 
side of  the  kidney,  causing  a  perinephritic  ab- 
scess. The  stone  escaped  with  the  pus  and  was 
found  lying  outside  of  the  kidney.  In  this  case, 
the  kidney  was  practically  destroyed  and  I  at- 
tempted to  remove  it,  but  found  the  adhesions  to 
the  surrounding  tissues  so  dense  anteriorly  and 
along  the  pedicle,  that  I  was  afraid  to  remove 
the  entire  organ  lest  I  tear  the  vena  cava.  I  ac- 
cordingly removed  half  of  it.  The  kidney  was 
so  fibrous  that  scarcely  any  blood  was  lost  dur- 
ing the  operation.  Fig.  309  shows  a  stone  that 
was  discharged  from  the  kidney  into  the  renal 
fossa  when  a  kidney  abscess  discharged  through 
its  capsule,  giving  rise  to  a  perinephritic  abscess. 
The  half  of  the  kidney  removed  was  a  mass  of  fibrous  tissue.  The  piece  re- 
maining was  evidently  nonfunctionating,  as  no  permanent  urinary  sinus 
remained  in  the  loin. 

The  local  treatment  of  the  patient  after  the  operation  depends  upon  the 
operation  performed  and  the  existing  conditions.  In  a  case  of  nephrectomy 
in  which  a  large  pyonephrotic  kidney  has  been  removed  without  any  infection 
entering  the  renal  fossa,  the  wound  can  be  closed  and  the  patient  needs  no 
further  local  treatment  unless  some  complication  develops.  But  when  a  nephrec- 
tomy immediately  follows  a  nephrotomy,  or  in  the  case  of  a  secondary  nephrec- 
tomy, a  cigarette  drain  should  be  passed  down  to  the  pedicle  of  the  stump,  as 
the  wound  has  probably  been  infected  by  the  leakage  of  pus  during  the  nephrot- 
omy operation. 

Temperature  and  Pulse. — After  operation,  the  temperature  and  pulse  range 
as  follows:  On  the  day  of  operation,  the  temperature  ranges  from  98.6°  to 
100°  F.  and  the  pulse  from  90  to  140;  the  temperature  ranges  from  98.6°  to 
99°  F.  in  a  mild  case,  and  100°  F.  or  more  in  one  with  more  severe  symptoms. 

On  the  first  day  after  the  operation,  the  temperature  in  mild  cases  ranges 
from  98.2°  to  100°  F. ;  in  others  from  100°  to  102°  F.  The  pulse  in  mild 
cases  ranges  from  90  to  106 ;  in  others  from  100  to  130. 

On  the  second  day  after  the  operation,  the  temperature  in  mild  cases  was 
from  99°  to  100°  F. ;  in  others  from  100°  to  102°  F.  The  pulse  in  mild  cases 
was  from  85  to  100  ;  in  others  from  100  to  130. 


520  NEPHROLITHIASIS 

On  the  third  day,  the  temperature  in  mihl  eases  was  from  98.6°  to  99.2°  F. ; 
in  others  from  103°  to  106°  F.,  nsnally  fatal.  The  pulse  in  mild  cases  was 
from  80  to  100;  in  others  from  100  to  130  or  even  KiO,  usually  fatal. 

In  favorable  cases,  the  temperature  and  pulse  become  normal  in  from  four 
to  six  days ;  first  of  all  in  clean  nephrotomy  cases,  next  in  primary  nephrectomy 
cases  in  which  the  kidney  is  delivered  without  being  opened.  Cases  of  extensive 
pvelo-nephritis  and  pyonephrosis  are  apt  to  run  a  long  febrile  course  after  ne- 
phrotomy and  sometimes  do  not  reach  nornud  for  several  weeks.  The  course 
after  secondary  nephrectomy  is  indefinite,  frequently  requiring  two  weeks  or 
more  for  the  reestablishment  of  normal  pulse  and  temperature. 

A  temperature  of  101°  F.  and  a  pulse  of  130  on  the  second  or  third  day 
after  an  operation,  whether  it  be  nephrotomy  or  nephrectomy,  is  a  very  dan- 
gerous symptom.  A  slight  temperature  after  nephrotomy  points  to  a  slow 
absorption  of  pus  Avhile  the  walls  of  the  opening  down  to  the  kidney  are  closing 
together  to  form  a  sinus.  In  case  the  temperature  continues  to  go  up  slowly  to- 
gether with  sweating,  and  perhaps  chills,  we  must  think  of  a  general  sepsis.  If, 
on  the  other  hand,  the  temperature  goes  up  suddenly  and  the  drainage  is  found 
to  be  insufficient,  it  would  point  to  a  local  accumulation  of  pus  in  the  region 
of  the  kidney. 

The  treatment  of  these  cases  is  as  follows:  In  the  first  instance,  while  the 
drainage  tube  is  in  the  kidney,  the  renal  pelvis  should  be  washed  out  daily  with 
a  1 :  4,000  solution  of  nitrate  of  silver,  and  later,  when  the  tube  is  in  the  sinus 
leading  down  to  the  kidney,  this  opening  should  be  irrigated  twice  a  day  with 
1 :  2,000  solution  of  bichlorid.  In  case  of  an  abscess  formation  due  to  reten- 
tion of  pus  in  the  wound,  usually  about  the  kidney,  it  is  opened  by  blunt  dis- 
section, wdth  the  finger  or  otherwise,  and  afterwards  washed  out  with  peroxid 
of  hydrogen.  In  case  of  a  general  sepsis,  a  thorough  local  examination  is  made, 
any  pus  pockets  found  are  opened  and  the  whole  of  the  operative  area  is  then 
washed  out  twice  daily  with  peroxid  of  hydrogen.  The  patient  is  treated  in- 
ternally with  small  doses  of  quinin  three  times  a  day,  and  whisky  from  a  half 
to  one  ounce  as  often  as  indicated.  If  the  patient  does  not  improve  in  this  way, 
the  kidney  should  be  removed  by  a  secondary  nephrectomy. 

Urine  after  Operation. — After  a  nephrotomy,  blood  is  voided  in  the  urine 
for  from  one  to  ten  days.  The  urine  voided  varies  in  amount.  Usually  on  the 
first  day  after  the  operation  one  pint  is  voided  and  on  the  second  day  after  from 
one  to  one  and  one  half  pints  or  more,  dependent  upon  the  amount  of  water 
taken  and  the  activity  of  the  kidneys. 

After  a  nephrotomy,  there  are  always  changes  in  the  urinary  lialance,  that 
is,  the  amount  of  urine  voided  and  the  amount  leaking  away  from  the  renal 
pelvis  through  a  rubber  drainage  tube  into  a  bottle  by  the  bedside.  In  order 
to  observe  this  carefully,  a  chart  can  be  kept,  showing  the  gain  on  one  side  and 
the  loss  on  the  other. 


TKEATMENT  521 

Tdl'lc  SIi()ii'i)u/  CJiaiHjc.s  lib  (he  Amount  of  Urine  in  Ounces  Coming  from  [he 
Kidneys  Voided  after  Nephrotomy 

First  24  Hours  Second  24  Hours  Tliird  24  Hours 

Voided    24  28  34 

Drained 18  IG  13 

Fourth  24  Hours  Fifth  24  Hours  Sixth  24  Hours 

Voided    37  40  44 

Drained 11  9  8 

Sercnth  24  Hours 

Voided 47 

Drained 8 

In  case  the  anionnt  of  drainage  diminishes  to  a  certain  degree  and  then 
stops  and  remains  at  abont  that  figure  for  some  time,  the  decrease  will  be  again 
observed  after  inserting  a  ureteral  catheter  a  demeure. 

Sinuses  and  fistulas  have  been  observed,  after  both  nephrectomies  and  ne- 
phrotomies. In  nephrectomy,  a  suppurating  sinus  may  remain  until  the  ligature 
lias  become  either  absorbed  or  thrown  off.  After  nephrolithotomy,  fistulas  are 
said  to  follow  in  six  per  cent  of  cases  lasting  for  varying  periods — weeks,  months 
or  years.     Such  a  percentage  corresponds  in  the  cases  I  have  operated  upon. 

Mortality. — In  fatal  cases  following  nephrotomy,  the  patients  usually  die 
of  asthenia,  sepsis  or  uremia.  After  a  secondary  nephrectomy  is  performed  as 
well  as  in  primary  nephrectomy,  they  may  die  on  the  table  from  hemorrhage ; 
or  on  the  same  day  from  shock;  after  a  few  days  from  anuria;  or  later  from 
uremia  or  asthenia. 

One  clean  case  already  mentioned,  operated  upon  by  nephrotomy,  in  which 
the  renal  pelvis  was  in  good  condition  and  the  involved  kidney  but  little  dis- 
eased, died  in  sixty  hours  after  the  operation,  of  uremia  and  sepsis.  I  had 
closM  the  wound  in  this  patient  without  drainage,  but  on  the  following  day, 
Avhen  his  temperature  went  up,  I  opened  it  again,  washed  it  out  and  inserted 
drainage,  although  no  pus  was  present.  In  most  of  the  fatal  cases  of  nephrot- 
omy under  my  observation,  there  was  a  pyelo-nephritis  or  pyonephrosis  in  the 
diseased  organ  and  a  nephritis  in  the  other  kidney. as  well.  In  nephrectomy, 
the  deaths  were  usually  due  to  anuria  when  occurring  shortly  after  the  opera- 
tion, to  sepsis  when  the  period  was  somewhat  longer  and  to  uremia  when  the 
deaths  occurred  still  later.  All  my  nephrectomies  were  performed  on  patients 
with  septic  kidneys. 

Results  of  Operations. — ]\Iy  own  results  have  been  10  ]ier  cent  mortality  in 
nephrotomies  and  30  per  cent  in  nephrectomies;  mortality  in  partial  nephree- 


522  NEPHROLITHIASIS 

tomy,  none;  in  nephrostomy,  none.  Nearly  all  my  operations  have  been  in 
pus  cases,  aseptic  cases  having  been  exceptionally  rare. 

The  results  vary  greatly  according  to  the  presence  or  absence  of  septic  com- 
plications in  the  kidney,  thus:  (1)  In  aseptic  cases  the  mortality  after  nephrot- 
omy was  less  than  4  per  cent;  (2)  in  septic  the  mortality  after  nephrotomy 
was  20  per  cent,  but  has  been  as  low  as  10  per  cent;  (3)  in  septic  cases  (a) 
primary  nephrectomy  gave  a  mortality  of  33  per  cent,  which  of  late  has  been 
reduced  to  20  per  cent,  (&)  secondary  nephrectomy  gave  23  per  cent  mortality. 

In  a  number  of  cases  of  nephrolithiasis,  a  perinephritic  abscess  is  present 
when  we  first  see  the  patient.  In  these  cases,  there  is  often  a  large  amount  of 
pus,  distorting  the  tissues,  pushing  the  kidney  out  of  place  and  preventing  us 
from  examining  it  thoroughly.  In  all  such  cases,  having  made  an  incision, 
evacuated  the  pus  and  washed  out  the  cavity,  the  surgeon  should  insert  a  finger 
and  explore  the  cavity. 

Sometimes  the  kidney  can  easily  be  brought  to  view,  the  opening  explored 
with  the  finger,  or  a  nephrotomy  performed  at  the  time,  thus  allowing  better 
drainage.  If,  however,  it  is  difficult  to  examine  the  kidney  intelligently  at  this 
time,  the  drainage  should  simply  be  extrarenal,  the  drainage  tube  being  inserted 
in  the  most  dependent  part  of  the  abscess  cavity.  Then,  after  a  few  days, 
nephrotomy  can  be  performed. 

A  few  years  ago,  I  occasionally  used  to  do  a  nephrotomy  in  such  cases  at 
the  time  of  evacuating  the  abscess. 

Cases  of  calculous  kidney  giving  rise  to  perinephritic  abscess  are  usually 
those  in  which  the  suppuration  has  destroyed  the  parenchyma  as  far  as  the 
■  capsula  propria,  which  it  has  stretched  and  thinned  to  such  a  degree  that  it 
bursts  easily.  The  pus  escapes  into  the  perinephritic  tissue,  w^hereas  the  stone 
remains  in  the  kidney.  In  one  case,  a  sharp-pointed  calculus  was  found  pro- 
truding three  quarters  of  an  inch  beyond  the  surface  of  the  kidney.  A  nephrot- 
omy was  performed,  the  stone  was  pulled  out  of  the  kidney  through  the  incision 
and  the  remainder  of  the  kidney  explored  (Fig.  290).  In  another  case,  that 
has  already  been  mentioned .  under  Partial  jS^ephrectomy,  the  stone  had  been 
discharged  with  the  pus  in  the  abscess  cavity  and  lay  outside  of  the  kidney 
(Fig.  309). 

Calculous  Anuria. — When  anuria  accompanied  by  pain  suddenly  develops 
in  a  case  of  nephrolithiasis  due  to  ureteral  obstruction  by  a  calculus,  an  anti- 
spasmodic should  be  given,  as  morphin  and  atropin  hypodermically,  and  a  mix- 
ture containing  15  grains  of  acetate  of  potash  and  15  minus  spts.  etheris 
nitrosi,  every  two  hours,  to  see  if  the  ureter  can  be  flushed  and  the  obstruction 
removed.  While  this  process  of  flushing  is  under  way,  it  is  well  to  cystoscope 
the  patient  and  to  attempt  to  catheterize  the  ureters  in  order  to  locate  the 
obstruction.  Sometimes  the  ureteral  catheter  will  prove  valuable  by  encoun- 
tering a  calculus  and  pushing  it  back  into  the  pelvis  or  by  controlling  a  ure- 


CALCULOUS    ANURIA  523 

teral  spasm.  Where  this  procedure  fails,  however,  and  we  have  satisfied  our- 
selves concerning  the  condition  of  the  kidneys  and  ureters,  it  is  not  advisable 
to  wait  until  uremic  phenomena  develop,  if  they  have  not  already  done  so,  be- 
fore operating,  as  we  know  that  uremia  will  set  in  unless  the  obstruction  is 
removed  and  that  the  operation  is  usually  very  effective.  The  method  of  choice 
is  nephrotomy,  which  is  readily  performed  and  promptly  beneficial  through 
bleeding  and  removing  renal  and  ureteral  tension.  The  stone  or  stones  may  be 
removed,  if  met  with,  by  the  finger  introduced  into  the  renal  pelvis  or  the 
upper  ureter.  A  prolonged  search,  however,  is  not  advisable,  for  the  reason 
that  anesthesia  is  always  dangerous  in  these  patients  whose  kidneys  have  al- 
ready ceased  to  functionate.  It  is  sufficient,  therefore,  to  pass  the  catheter 
down  the  ureter  in  the  hope  of  freeing  the  obstruction  from  above.  The  pres- 
sure having  been  removed  by  the  nephrotomy,  the  ureteral  spasm  ceases  and 
the  stone  may  pass  down  into  the  bladder,  and  if  not,  an  operation  for  its  re- 
moval can  be  performed  later.  These  kidneys  are  usually  very  much  distended 
and  the  gush  of  blood  and  urine  after  the  incision  is  very  abundant.  I  have 
operated  in  such  a  case  five  days  after  anuria  had  set  in  and  when  there  was  no 
pain  and  almost  no  symptom  of  uremia.  The  other  kidney  is  usually  in- 
capacitated. 

■  The  unilateral  location  of  the  colics,  tenderness  on  pressure,  increase  in  size 
of  the  kidney  and  ureteral  catheterization  will  serve  to  indicate  the  side  to  be 
operated  on.  Where  obstruction  has  been  found  on  both  sides,  a  double  nephrot- 
omy may  be  performed,  or,  in  case  this  is  forbidden  by  the  general  condition 
of  the  patient,  the  incision  is  best  made  in  the  side  which  has  been  last  affected. 
There  are  probably  many  people  who  consider  themselves  healthy  and  yet 
have  but  one  functionating  kidney,  the  other  having  been  destroyed  through  a 
blocking  of  the  ureter  by  calculus  or  a  tuberculous  infiltration  years  before ;  or 
through  a  suppurative  process  that  has  destroyed  the  parenchyma,  A  kidney 
can  have  been  the  seat  of  a  small  calculus  that  gave  rise  to  suppuration  and  was 
then  passed  down  the  ureter  and  voided  in  the  urine ;  after  which  the  suppura- 
tive process  can  have  continued  until  the  kidney  has  been  destroyed,  or  the  stone 
may  have  remained  in  the  kidney  and  the  organ  been  destroyed  through  sup- 
puration. The  former  explanation  seems  improbable  and  yet  I  believe  it  can 
occur  and  will  quote  a  case  to  streng-then  my  belief.  The  latter  I  know  can 
occur. 

Illustrative  Case. — The  patient,  a  contractor,  forty-eight  years  of  age, 
had  not  passed  urine  for  five  days,  and  a  catheter  passed  into  his  bladder 
twice  daily  had  failed  to  find  any  fluid  there.  Five  years  prior  to  this  time,  he 
had  suffered  from  very  severe  pain  in  the  right  side,  lasting  for  some  time  and 
accompanied  by  fever ;  he  then  passed  two  calculi,  after  which  he  felt  perfectly 
well  and  had  considered  himself  so  up  to  his  present  illness.  When  the  pa- 
tient came  under  observation,  there  were  no  uremic  symptoms-  except  slight 


524  NEPHEOLITHIASIS 

drowsiness;  he  had  a  slight  cough  and  a  few  sonorous  rales.  Pain  had  been 
present  during  the  first  two  days  of  the  attack,  but  had  disappeared.  Cystoscopy 
was  performed  and  no  urine  was  found  in  the  bladder.  No  urine  escaped  on 
introduction  of  a  cathet-er  into  the  pelvis  of  the  right  kidney;  the  left  ureter 
was  obstructed  just  above  the  bladder  wall. 

Treatment.- — Left  nephrotomy  with  drainage.  Two  days  later  the  patient 
began  to  pass  urine  by  the  urethra.  The  ureters  were  again  catheterized,  and  the 
right  side  was  still  found  to  be  free,  but  no  urine  came  away.  The  left  side  was 
now  unobstructed,  the  stone  having  been  passed  out,  and  the  kidney  was  drain- 
ing again  through  the  ureter  into  the  bladder. 


CHAPTER    XXIX 

TUBERCULOSIS  OF  THE  KIDNEY 

Historical  Data. — References  to  strumous  and  scrofulous  kidney  occur  in 
early  medical  literature,  and  Malpighi  is  known  to  have  devoted  considerable 
time  to  the  study  of  the  suppurative  processes  caused  by  this  condition.  The 
actual  history  of  renal  tuberculosis,  however,  is  intimately  connected  with  the  ad- 
vancing knowledge  of  tuberculosis  in  general,  and  is  therefore  relatively  brief. 
Klebs,  in  1887,  was  the  first  to  find  bacteria  constantly  present  in  tuberculous 
tissue,  which  produced  similar  lesions  when  inoculated  into  animals.  Five 
years  later,  the  specific  microorganism,  the  tubercle  bacillus,  was  discovered  by 
Koch.  This  discovery  was  followed  almost  immediately  by  the  demonstration 
of  the  bacillus  in  the  urine  by  Cohnheim. 

The  work  of  Koch  and  Cohnheim,  together  with  other  advances  in  surgical 
pathology,  have  enabled  us  to  gain  a  clear  insight  into  the  nature  of  renal  tuber- 
culosis, not  only  from  clinical  observation  backed  by  postmortem  findings,  but 
also  through  the  experience  gained  by  operating  at  various  stages  of  the  disease. 

Tuberculosis  of  the  genito-urinary  organs  is  always  secondary  to  the  dis- 
ease elsewhere,  as  in  the  glands,  bones  or  lungs.  A  primary  focus  of  tuber- 
culosis is  said  to  occur  occasionally  in  the  kidney:  that  is,  before  any  other 
organ  or  tissue  is  invaded.  Such  cases  are,  however,  so  open  to  question  that  it 
is  better  for  us  to  consider  tuberculosis  of  the  genito-urinary  tract  as  a  sec- 
ondary manifestation  to  a  condition  elsewhere  in  the  body.  Therefore,  when 
I  use  the  expression  "  primary  tuberculosis  of  the  kidney,"  I  mean  that  the 
disease  is  present  in  one  kidney  and  not  as  yet  in  the  other.  It  occurs  pri- 
marily in  one  kidney  in  about  fifty  per  cent  of  cases.  If,  however,  we  use  the 
word  "  primarily  "  in  the  kidney,  we  will  mean  before  it  occurs  elsewhere  in 
the  body. 

Tuberculosis  occurs  in  the  kidney  more  frequently  than  in  any  other  organ 
of  the  genito-urinary  tract;  in  fact,  about  as  often  as  in  all  the  other  organs 
put  together.  According  to  Walker,  in  a  series  of  279  cases,  the  part  of  the 
genito-urinary  tract  invaded  first  was  the  kidney  in  184  cases,  the  epididymis 
in  80,  the  prostate  in  3,  the  Fallopian  tube  in  3,  the  seminal  vesicles  in  2  and 
the  uterus  in  1  case. 

It  would  appear  from  these  observations  that  tuberculosis  of  the  bladder 

525 


526  TUBERCULOSIS    OF    THE   KIDNEY 

is  never  a  primary  disease  of  the  genito-urinary  tract,  but  that  it  is  usually 
secondary  to  that  of  the  kidney  or  epididymis ;  in  the  first  instance  descending 
along  the  ureter,  and  in  the  second  invading  the  bladder  through  the  prostate. 
Halle  and  Motz,  in  one  hundred  of  their  own  cases,  found  several  in  which 
tuberculosis  was  present  in  the  renal  pelvis  and  ureter  together  with  an  involve- 
ment of  the  kidney  on  that  side  and  not  of  the  bladder. 

Tuberculosis  of  the  kidney  is  of  two  forms :  The  acute  or  miliary,  which  is 
a  part  of  the  general  constitutional  disease,  and  the  chronic  form,  in  which 
there  is  a  cheesy  and  suppurative  degeneration  of  the  organ,  such  as  we  are 
accustomed  to  see  surgically. 

Tuberculosis  of  the  ureter  is  always  secondary  to  that  of  the  kidney  and  not 
to  that  of  the  bladder. 

The  most  common  age  at  which  tuberculosis  of  the  kidney  occurs  is  be- 
tween twenty  and  thirty.  In  autopsies  performed  at  the  Pathological  Institute  at 
Prague  on  adult  consumptives,  5.6  per  cent  were  found  to  have  renal  tuberculosis. 
Children  are  much  more  frequently  attacked  than  was  formerly  supposed  and 
in  315  cases  of  tuberculosis  15.7  per  cent  had  renal  involvement.  The  miliary 
form  is  more  frequent  in  children  and  the  chronic  or  caseous  form  in  adults 
(Ttilliet  and  Barthez).  Eight  per  cent  of  my  cases  were  in  patients  fourteen 
years  of  age  or  younger.  This  is  rather  a  large  percentage  in  a  practice  in 
which  nearly  all  the  patients  were  adults. 

Regarding  the  sex,  authorities  differ  as  to  whether  women  or  men  are  more 

frequently   affected.      The  latest  statistics  ■  show   that  it  is  more  common  in 

women.     It  is  more  frequent  on  the  right  side.     In  cases  that  I  have  studied, 

'54  per  cent  occurred  on  the  right  side,  28  per  cent  on  the  left  and  18  per  cent 

on  both  sides. 

Etiology. — The  predisposing  causes  of  tuberculosis  are,  first :  A  weakened 
condition  of  the  system,  w^hich  diminishes  the  resistance ;  and  second,  a  con- 
dition of  the  kidney  favoring  infection,  such  as  a  congestion  from  traumatism 
or  other  causes,  irritating  products  in  the  urine,  renal  stasis,  inflammation  of 
the  kidney,  renal  calculus  or  undue  mobility  of  the  organ.  Tuberculosis  in  the 
family  also  renders  the  patient  more  susceptible  to  tuberculosis  in  general  or 
the  kidney  in  particular.  A  tuberculous  family  history  w^as  common  in  my 
cases. 

The  active  cause  is  the  entrance  of  the  tubercle  bacillus  into  the  organ.  It 
is  said  that  tubercle  bacilli  can  pass  through  a  normal  kidney,  bladder  and 
urethra  wdthout  giving  rise  to  urinary  tuberculosis,  but  that  when  the  germ 
finds  the  proper  conditions,  such  as  have  been  mentioned  under  predisposing 
causes,  it  will  remain  there  and  infect  the  organ. 

It  has  been  shown  that  the  tubercle  bacillus  can  reach  the  urine  through  the 
hematogenous  and  lymphogenous  route,  or  that  it  can  pass  upward  from  the 
bladder.     It  is  probable,  however,  that  in  nearly  all  cases  the  bacilli  reach  the 


PATHOLOGY  527 

kidney  through  the  general  circulation,  and  Lnt  rarely  by  the  way  of  the  ureter 
or  the  lymphatic  channels.  The  ascending  theory  of  infection  does  not  appeal 
to  me,  as  it  is  highly  improbable  that  bacilli  often  work  their  way  upward 
against  the  descending  current  of  urine,  and  I  believe  that  such  infection  can 
take  place  only  when  certain  rare  conditions  are  present. 

In  regard  to  the  occurrence  of  primary  tuberculosis,  some  observers  state 
that  primary  tuberculosis  frequently  occurs  in  one  kidney ;  others  claim  that 
tuberculosis  is  never  primary  in  the  kidney,  but  always  secondary  to  that  in 
some  other  part  of  the  body.  Such  statements  are  difficult  to  understand.  It 
is  safer  to  say  that  tuberculosis  never  occurs  in  one  kidney  primarily,  that  is, 
before  it  does  in  any  other  organ  or  tissue.  This  is  corroborated  by  many, 
who  say  that  there  are  only  five  cases  of  primary  unilateral  tuberculosis  of  the 
kidney  on  record  in  which  the  autopsy  showed  no  other  tubercular  lesion  in 
the  body,  and  these  are  questionable. 

It,  therefore,  seems  to  me  that  in  a  clinical  consideration  of  the  subject  we 
can  sum  up  these  various  statements  by  saying  that  tubercle  bacilli,  from  what- 
ever source,  passing  through  the  renal  circulation,  by  the  blood  or  by  the 
lymphatics,  may  infect  a  congested  kidney  with  tuberculosis ;  that  the  infection 
usually  takes  place  in  one  kidney  before  it  does  in  the  other  and  that  the  other 
kidney  will  probably  not  be  involved  if  the  diseased  one  is  removed  at  a  suffi- 
ciently early  date. 

As  we  have  already  stated,  tuberculosis  occurs  in  one  kidney  in  about 
fifty  per  cent  of  the  cases,  and  we  generally  find  it  confined  to  one  kidney  in 
that  percentage  of  cases  presenting  themselves  for  treatment.  Such  an  opinion 
is  based  principally  on  clinical  findings  and  many  surgeons  claim  a  higher  per- 
centage of  unilateral  tuberculosis ;  but  it  must  be  remembered  that  we  cannot 
always  tell  whether  the  second  kidney  is  clinically  involved  or  not,  as,  during 
the  stage  of  invasion  and  development,  tubercle  bacilli  are  extremely  hard  to 
find  in  the  urine,  which  contains  but  few  pathological  products  of  the  disease. 
On  the  other  hand,  the  postmortem  examination  in  renal  tuberculosis  shows  a 
smaller  percentage  of  unilateral  disease,  but  here  we  must  consider  the  fact 
that  in  such  cases  the  disease  is  much  more  advanced  than  when  the  surgeon 
makes  his  clinical  examination. 

Secondary  suppurative  processes  in  tuberculous  kidney  are  due  to  infection 
with  pyogenic  germs,  usually  the  Staphylococcus  aureus,  the  colon  bacillus  or 
the  streptococcus.  The  colon  bacillus  may  enter  the  kidney  through  the  circu- 
lation, or  it  may  ascend  from  the  bladder  or  may  migrate  to  the  kidney  from 
the  colon ;  whereas  the  other  two  enter  either  through  the  circulation  or  accom- 
pany a  mixed  infection  from  below  upward. 

Pathology. — The  two  types  of  tuberculosis  of  the  kidney  are  the  miliary 
and  the  caseating.  The  miliary  form  occurs  particularly  in  a  general  tuber- 
culosis  and   is   characterized   by   the   presence   of  miliary   tubercles   scattered 


528 


TUBERCULOSIS    OF    THE    KIDNEY 


throughout  the  tissue  of  the  organ,  often  near  the  surface  beneath  the  capsule, 
so  that  they  may  be  seen  on  inspection  before  the  kidney  is  cut  open.  On  sec- 
tion, they  are  often  found  present  in  the  cortex  of  the  kidney  in  the  shape  of 
small  whitish  or  yellow  spots. 


^, 


Fig.  310. — Clusters  of  Tubercles  on  the  Outside  of  the  Kidney.  They  appear  to  be  of  the 
miliary  type,  yet  the  author  has  in  his  collection  numerous  kidneys  with  such  lesions  seen  under 
the  capsule  which  have  cavities  in  their  interior  three  quarters  of  an  inch  in  diameter.  (From 
Van  Bergman.) 


/ 


y 


Fig.  311. — The  Same  Kidney  as  in  Fig.  310,  Shown  in  Section.  Note  the  arrangement  of  the  tuber- 
culous deposits.  This  is  the  beginning  of  an  acute  tuberculosis.  The  type  is  miliary,  but  the 
result  may  be  great  destruction  and  extensive  cavity  formation.     (From  Van  Bergman.) 

The  caseating  form  is  characterized  by  the  presence  of  grayish  or  yellowish 
cheesy  nodules  scattered  throughout  the  substance  of  the  kidney  which  is  usually 


PATHOLOGY 


529 


enlarged  and  sliglitly  nodidated.  These  nodules  are  filled  with  necrosed  tissue 
detritus  and  are  surrounded  by  interstitial  fibrous  tissue.  The  outcome  of 
the  process  of  a  pure  infection  with  the  tubercle  bacillus  is  in  cicatrization  and 
contraction  of  the  scar  tissue,  sometimes  even  leading  to  an  occlusion  of  the 
ureter,  the  disappearance  of  the  pelvis  and  destruction  of  the  kidney  paren- 
chyma. Figs.  310  and  311  show  clusters  of  tubercles  resembling  the  miliary 
type.  I  have  frequently  removed  kidneys,  that  I  have  in  my  collection,  with 
superficial  appearance  normal  in  one  pole,  whereas  in  the  other  pole  there 
were  cavities  an  inch  in  diameter. 

When  a  secondary  infection  occurs,  due  to  the  entrance  of  pus-prodneing 
germs,  the  caseating  nodules  enlarge,  suppurate  and  discharge  into  the  renal 
pelvis  (Fig.  312),  or  occa- 
sionally under  the  fibrous 
capsule,  in  which  latter  case 
they  may  break  through  it 
and  give  rise  to  a  perine- 
phritic  abscess  (Fig.  286). 
The  renal  pelvis  is  sometimes 
involved  simultaneously  with 
the  kidney,  but  generally 
later,  after  infection  has 
taken  place  and  the  tubercu- 
lar cavities  have  broken  into 
the  pelvis ;  in  that  case  the 
urine  will  contain  tubercle 
bacilli  and  portions  of  ne- 
crotic tissue.  A  tubercular 
cavity  containing  softened 
matter  and  pus,  sometimes 
spoken  of  as  a  tubercular 
cyst,  may  break  both  into  the 
renal  pelvis  and  through  the 
renal  capsule,  giving  rise  to 
a  renal  fistula  and  perine- 
phritic  abscess.  I  have  seen 
such  a  condition  in  a  num- 
ber of  cases  and  have  been 
able  to  pass  my  finger  from  without  the  kidney  into  the  pelvis.  When  the  renal 
tissue  has  been  more  extensively  destroyed,  the  cavernous  areas  become  more 
marked  and  are  separated  by  walls  of  fibrous  tissue.     (See  Fig.  314.) 

The  various  forms  of  disease  that  we  see,  after  a  secondary  infection  by 
pus-producing  bacteria  has  taken  place,  are  abscess  of  the  kidney,  pyelo-nephri- 


FiG.  312. — A  Case  in  which  the  Tuberculous  Abscesses 
Have  Broken  into  the  Pelvis,  Giving  Rise  to  Pyelo- 
nephritis.    (Author's  case.) 


530  TUBEECULOSIS    OF    THE   KIDNEY 

tis  and  pyoneplirosis.  Abscess  of  the  kidney  shows  itself  as  a  circumscribed 
collection  of  pus  and  tubercular  detritus  in  the  renal  parenchyma,  usually  the 
cortical  portion,  which  may  or  may  not  break  into  the  renal  pelvis.  Pyelone- 
phritis is  a  condition  occurring  when  the  nodules,  after  infection,  soften,  liquefy 


Fig.  313. — Pyelonephbitic  Kidney  6  Inches  Long. 
Note  the  pus  cavities,  especially  in  the  lower  pole.     (Author's  case.) 

and  discharge  into  the  pelvis,  leaving  a  tract  leading  to  a  pus  cavity.  Pyelo- 
nephrosis  or  pyonephrosis  is  a  phase  of  pyelo-nephritis  in  which  many  abscesses 
have  discharged  into  the  pelvis,  and  the  kidney  parenchyma  consists  of  a  num- 
ber of  pus  cavities,  discharging  into  the  pelvis,  separated  from  one  another  by 
fibrous  walls.  A  thickened  or  strictured  ureter  may  also  give  rise  to  urinary 
and  pus  retention,  with  a  dilated  pelvis  and  destruction  of  the  parenchyma  by 
pressure  and  suppuration,  constituting  another  form  of  pyonephrosis.  Pirn's. 
313  and  314  are  two  kidneys  from  the  same  patient.  Fig.  313  is  a  pyelo- 
nephritic  kidney  and  Fig.  314  is  a  pyonephrotic  kidney. 

A  ureter  may  be  occluded  by  a  tuberculous  thickening  of  its  walls,  in  which 
case  there  is  usually  a  dilatation  behind  it ;  or,  if  the  process  is  more  complete, 
it  may  be  converted  into  a  fibrous  cord.     If  such  a  change  takes  place,  the  cor- 


PATHOLOGY 


531 


responding  tuberculous  kidney  may  develop,  in  consequence  of  ureteral  occlu- 
sion, a  pyonephrosis  depending  in  size  upon  whether  the  occlusion  has  taken 
l^lace  rapidly  or  slowly.  Fig,  315  is  a  specimen  removed  at  autopsy  from  an 
inoperable  case  of  urinary  tuberculosis  on  my  service  at  the  Columbus  Hospital. 
The  tuberculous  process  had  entirely  occluded  the  right  ureter,  giving  rise  to 
an  atrophic  kidney,  whereas,  on  the  left  side,  it  but  partially  occluded  the  ure- 
ter, causing  pyonephrosis  and  renal  enlargement. 

The  appearance  of  the  two  kidneys  in  this  form  of  tuberculosis  may  differ 
greatly  macroscopically,  as  in  the  same  case  we  may  have  the  following  condi- 
tions :  One  kidney  healthy,  the  other  larger  or  smaller  than  normal,  in  any  stage 
of  involvement  or  degeneration.     If  both  kidneys  are  involved,  one  may  be  in- 


FiG.  314. — Pyonepheotic  Kidney  7  Inches  Long.     Note  the  large  cavities  in  all  parts  of  the  organ 
separated  by  septae;  also  the  thickened  pelvis  and  ureter.     (Author's  case.) 

fected  with  the  tubercle  bacillus  alone  and  the  other  by  both  tubercle  bacilli 
and  the  germs  of  suppuration  (mixed  infection)  ;  in  other  words,  one  side 
may  be  undergoing  a  nonsuppurative,  caseous  degeneration  and  the  other  kid- 
ney both  a  caseating  and  suppurative  process. 


532 


TUBERCULOSIS    OF   THE   KIDXEY 


One  kidney  may  be  in  a  state  of  pyelo-nephritis  and  the  other  in  a  state  of 
pyonephrosis.  Usually,  if  both  sides  are  involved  with  a  mixed  infection,  it  is 
a  pyelo-nephritis.  In  case  of  a  pyonephrosis  on  one  side  and  a  pyelo-nephritis 
on  the  other  side,  the  pyonephrosis  is  usually  a  slower  process,  less  acute,  with 


Fig.  315. — A  Case  of  Urinary  Tuberculosis  Ija'^olving  Both  Ureters  and  Both  Kidneys.  On 
the  right  side  the  ureter  became  rapidly  imperforate,  due  to  a  stricture  near  the  kidney  and  to  a 
tuberculous  thickening  near  the  bladder,  with  a  consequent  atrophy  of  the  corresponding  kidney; 
size  3%  inches.  On  the  left  side,  the  occlusion  of  the  ureter  was  slow  and  incomplete,  resulting  in 
a  large,  thickened  kidney  with  pyonephrosis;  size  7  inches.     (Author's  case.) 

ureteral  thickening;  the  kidney  itself  is  larger  than  the  pyelo-nephritic  kidney 
on  the  other  side,  which  is  more  acutely  inflamed.  In  the  case  of  pyonephrosis 
of  both  sides,  one  organ  is  usually  larger  than  the  other  and  this  is  the  kidney 
whose  ureter  is  not  so  much  thickened  by  the  tuberculous  process.  (See  Fig. 
315.) 

A  tuberculous  kidney  may  be  in  any  condition  from  being  the  seat  of  a 
sin&'le  small  nodule  to  such  extensive  defeneration  that  the  functionating  tissue 

o  o  o 

of  the  organ  is  entirely  destroyed,  only  a  fibrous  tissue  mass  or  a  shell  remain- 


SYMPTOMS 


533 


ing  (Fig.  316).  Both  kidneys  may  be  in  the  first-named  condition  without 
giving  rise  to  clinical  symptoms ;  whereas  such  a  grave  change  as  the  one  re- 
ferred to  in  the  second  instance,  occurring  in  but  one  organ,  would  be  incom- 
patible with  life,  unless  the  other  kidney  was  perfectly  healthy. 

These  changes  in  size,  shape  and  appearance  of  the  kidneys  depend  upon 
the  rapidity  or  slowness  of  the  process,  the  amount  of  thickening  or  stricture 
formation  in  the  ureters,  the  j^rescnce  of  areas  of  cheesy  degeneration  or  of 
abscesses,  the  amount  of  kidney  tissue  that  has  been  destroyed,  the  presence  of 
single  or  mixed  infection  and  the  variety  of  mixed  infection. 

Various  lesions  may  be  found  associated  with  those  of  renal  tuberculosis, 
as  calculi  or  neoplasms ;  the  perinephritic  tissue  may  be  the  seat  of  sclerotic, 


Fig.  316. 


-Tuberculous  Kidney  in  which  the  Functionating  Renal  Tissue  Has  Been  Entirely 
Destroyed  by  the  Disease.     (Author's  collection.) 


sujipurative  or  lipomatous  changes,  and  the  lymph  nodes  of  the  hihim  may  par- 
ticipate in  the  tuberculous  process.  The  bladder  may  be  the  seat  of  tubercu- 
losis before  or  after  the  invasion  of  the  kidney.  The  male  genital  apparatus 
may  be  infected  at  the  same  time ;  but  tuberculosis  of  the  generative  organs  is 
much  less  common  in  women  and  usually  located  in  the  tubes  when  it  does 
occur,  which  is  only  about  one  sixth  as  often  as  in  the  male. 

Symptoms. — Acute  cases  of  renal  tuberculosis  are  of  the  miliary  type  and 
occur  in  persons  suffering  from  the  general  form  of  the  disease,  and  this  is  a 
condition  which  concerns  the  physician  rather  than  the  surgeon.      The  form 


534 


TUBERCULOSIS    OF    THE    KIDNEY 


of  renal  tuberculosis  that  the  surgeon  is  usually  called  upon  to  treat  is  the 
chronic  or  caseating  variety.  It  begins  insidiously  in  the  majority  of  cases  and 
it  is  said  by  some  that  it  may  not  show  itself  by  any  clinical  manifestations 
for  years,  or  perhaps  never  during  the  lifetime  of  the  patient ;  while  others  say 
that  an  ordinary  case  will  only  live  three  years  after  its  first  evidence.  I  think 
it  safe  to  say  that  renal  tuberculosis  will  show  symptoms  in  less  than  a  year 
in  nearly  every  case.  The  symptoms  may  be  so  slight,  however,  as  not  to  be 
recognized,  as,  for  instance,  in  cases  where  one  or  two  caseating  nodules  occur 
in  one  kidney  in  a  patient  whose  resistance  is  sufficient  to  overcome  the  dis- 
ease ;  in  this  case  the  nodules  will  become  encapsulated  and  the  process  arrested. 

The  duration  of  the  disease  in  the  patients  coming  to  me  for  treatment, 
estimated  on  the  basis  of  symptoms,  had  been  from  four  days  to  four  years, 
with  an  average  of  fifteen  weeks. 

The  symptoms  of  tuberculous  kidney  are  subjective,  objective,  general  and 
local.  The  reflex  symptoms  in  this  disease  may  lead  one  away  from  the  affected 
region  to  look  for  the  cause  in  other  directions,  the  same  as  in  nephrolithiasis ; 
for  here  we  have  also  the  reno-vesical  reflex  by  which  the  symptoms  are  referred 
to  the  bladder  instead  of  to  the  kidney,  and  also  the  reno-renal  reflex  in  which 
the  symptoms  are  referred  to  the  healthy  or  healthier  kidney. 


Subjective  symptoms 


Objective  symptoms 


General  symptoms 


Local  symptoms  (found 
on  examination) 


'Pain  in  the  loin. 
Pain  in  the  bladder. 
Tenesmus. 
Burning. 
Prequency  of  urination   (pollakiuria). 

Increased  amount  of  urine  (polyuria). 

Hematuria. 

Pyuria. 

'  Pever. 

Sweating  and  chills. 
Loss  of  appetite. 
Loss  of  weight  and  strength. 

Tumor. 

Abdominal  tenderness  ;  muscular  rigidity. 

Swelling  or  suppuration  of  glands,  genitals,  bones, 

joints  or  elsewhere. 
The  results  of  such  involvements  as  pointed  out  by 

sinuses,  scars  or  deformities. 


Subjective  Symptoms. — Pain  in  the  Loin. — In  many  cases  there  is  no 
local  pain.     When  present,  pain  in  the  loin  is  generally  dull  in  character,  al- 


SYMPTOMS  535 

though  it  is  severe  when  the  process  is  acute  and  attended  by  much  congestion. 
After  the  first  stages  of  tuberculosis  of  the  kidney,  when  the  organ  has  been 
extensively  destroyed,  the  pain  is  not  so  severe  as  while  the  inflammation  is 
more  acute  and  there  is  consequently  more  tension  in  the  organ.  However, 
during  the  destructive  process,  when  masses  of  necrosed  tissue  are  being  passed 
down  the  ureter,  a  renal  colic  may  take  place,  leaving  the  kidney  free  from 
pain  after  it  has  subsided. 

The  pain  may  be  in  the  kidney  that  is  the  least  involved  if  the  inflammation 
is  more  acute  on  that  side;  or  it  may  be  in  a  healthy  kidney  if  additional  work 
is  suddenly  thrown  upon  it.  This  is  probably  the  explanation  of  what  is  known 
as  the  reno-renal  reflex. 

The  following  statistics  are  from  the  records  of  cases  that  I  have  had  under 
observation. 

PAIN  IN  THE  kidney:  Eighty-three  per  cent  had  pain,  seventeen  per  cent 
had  no  pain. 

CHARACTER   OF   PAIN  : 

Pain  in  the  loin — more  or  less  steady 43  per  cent. 

Pain  increasing  gradually   4    "      " 

Pain  and  muscular  rigidity 18    "      " 

Double  pain 4    "      " 

Pain  on  exercise 7    '^      " 

Kenal  colic 7    "      " 


Total    83 


a         a 


Pain  in  the  bladder,  that  is,  in  the  perineum  or  suprapubic  region,  may  be 
the  most  marked  and  constant  symptom  associated  with  renal  tuberculosis  and 
nearly  always  occurs  when  the  pathological  process  exists  in  this  viscus.  Vesi- 
cal tuberculosis  is  very  frequent  and  should  always  lead  us  to  investigate  the 
kidneys,  even  if  there  is  no  pain  or  other  symptoms  in  those  organs.  Twenty- 
five  per  cent  of  the  cases  above  referred  to  had  vesical  pain. 

Tenesmus  is  a  symptom  in  almost  all  cases  of  reno-vesical  tuberculosis  in 
which  there  is  bladder  pain,  as  is  also  burning  on  urination  and  frequent 
urination. 

Frequency  of  urination  may  occur  for  two  reasons,  first  on  account  of  the 
bladder  irritation  when  the  tuberculous  process  has  invaded  it,  and  secondly 
on  acccount  of  the  greater  amount  of  urine  which  is  secreted  from  the  tubercu- 
lous kidney.  This  frequency  is  noted  during  both  the  day  and  night  and  when 
due  to  vesical  tuberculosis  is  apt  to  prove  very  fatiguing,  the  patient's  sleep  in 
certain  cases  being  very  much  interrupted  by  the  frequent  calls  to  pass  urine. 
When  frequency  occurs  in  connection  with  pain  and  tenderness,  it  is  not  due 
to  an  associated  reno-vesical  reflex,  as  was  formerly  supposed,  but  to  an  asso- 


536  TUBEKCULOSIS   OF   THE   KIDNEY 

ciated  tuberculous  cystitis.  The  amount  of  such  frequency  depends  upon  the 
seat  of  the  tuberculous  lesion  in  the  bladder,  being  the  greater  the  nearer  the 
lesion  is  to  the  neck  of  that  organ  or  to  the  sphincter  muscle.  This  I  proved 
conclusively  by  eystoscopic  examinations. 

Objective  Symptoms. — Polyuria  is  a  very  common  and  important  symp- 
tom. The  urine  is  of  low  specific  gTavity  and  closely  resembles  that  of  inter- 
stitial nephritis,  being  often  diagnosticated  as  such. 

Hematuria  is  also  a  frequent  symptom.  The  blood  is  generally  thoroughly 
mixed  with  urine,  although  sometimes  it  is  passed  as  ureteral  clots,  Avhich  are 
long  and  slender.  It  often  occurs  suddenly,  without  cause,  and  disappears  in 
the  same  way.  It  is  not  induced  by  motion  or  jarring.  Sometimes  the  hema- 
turia is  more  constant,  there  are  no  ureteral  clots,  and  the  blood  is  more  thor- 
oughly mixed  with  the  urine.  Besides  this,  the  hematuria  is  often  accompanied 
by  frequency  of  urination  and  tenesmus,  in  which  case  it  is  referable  to  tuber- 
culous lesions  in  the  bladder.  Blood  in  the  urine  may  be  the  only  local  symp- 
tom of  renal  tuberculosis  during  the  early  stages,  before  suppuration  has  begun. 
This  condition  in  tuberculous  kidney  is  sometimes  compared  to  hemoptysis  in 
the  pulmonary  form  of  the  disease.  There  was  a  history  of  hematuria  in  fifty 
per  cent  of  the  cases  under  observation. 

Pyuria  is  a  frequent  symptom  and  does  not  occur  until  a  secondary  infection 
has  taken  place.  This  is  usually  due  to  the  stajDhylococcus  or  the  colon  bacillus, 
or  in  the  more  acute  cases  to  the  streptococcus;  generally  it  is  not  until  pus 
appears  that  the  tubercle  bacilli  are  found. 

General  Symptoms. — Among  the  important  general  symptoms  are  loss  of 
appetite,  strengi;h  and  weight.  The  last  is  very  important,  as  it  is  often  a  meas- 
ure of  the  invasion  and  rapidity  of  its  progTess. 

Fever. — The  temperature  change  of  renal  tuberculosis  may  be  slight,  as 
from  normal  in  the  morning  to  99°  F.  in  the  evening;  or  it  may  run  from  102° 
to  105°  !F.,  or  any  degrees  between  these  figures,  depending  upon  the  variety 
of  the  secondary  infection.  Of  my  cases,  forty-five  per  cent  had  a  temperature 
before  operation  varying  from  98.4°  to  99°  F.  in  mild  cases  and  from  100°  to 
105°  F.  in  serious  cases. 

Sweating  and  chills  are  signs  of  secondary  infection  and  the  absorption  of 
pus  after  the  suppurative  processes  have  begun.  In  this  stage,  the  loss  of  iveight 
and  strength,  as  well  as  of  appetite,  may  be  very  marked. 

Diagnosis. — Examination. — Palpation  of  the  loin  may  reveal  an  enlarge- 
ment of  the  kidney,  abdominal  tenderness  or  muscular  rigidity. 

The  presence  of  a  tumor  in  the  loin,  that  is,  a  palpable  kidney,  is  frequent 
during  the  stage  of  caseation  and  still  more  so  after  secondary  infection  has 
taken  place  and  a  pyelo-nephritis  or  pyonephrosis  has  developed.  The  absence 
of  an  appreciable  tumor,  however,  does  not  argue  against  the  existence  of  a 
tuberculous  kidney,  as  it  may  not  be  outlined  owing  to  muscular  rigidity ;  or 


DIAGNOSIS  537 

in  the  stage  of  pyonephrosis  it  may  be  so  destroyed  as  to  be  smaller  than  a 
normal  kidney ;  or  it  may  be  large,  but  so  soft  and  pliable  that  it  cannot  be 
outlined.  The  kidney  shown  in  Fig.  313  is  smaller  than  its  mate,  while  in 
Fig.  314  the  kidney  is  very  large  but  so  soft  that  it  could  not  be  outlined  until 
the  patient  had  been  anesthetized. 

Tenderness  over  the  kidney  is  often  present  and  at  times  extreme.  It  can 
be  best  detected  by  deep  pressure  on  the  kidney  between  the  fingers  of  one 
hand  on  the  abdomen  and  of  the  other  hand  behind,  just  below  the  twelfth  rib. 
At  times,  there  is  tenderness  anteriorly  on  surface  palpation,  wdien  the  kidney 
is  acutely  inflamed ;  in  this  case,  the  kidney  of  that  side  may  not  be  so  seriously 
involved  as  the  other  organ,  but  more  acutely  inflamed.  Muscular  rigidity  is 
also  often  present  over  the  kidney  on  the  anterior  abdominal  wall,  the  same  as 
over  the  appendicular  region  in  case  of  appendicitis. 

In  suspected  cases  of  renal  tuberculosis,  tuberculous  manifestations  of  the 
lungs,  the  glands,  the  joints  or  the  genitals  are  corroborative  of  its  presence ; 
Avhile  a  history  of  such  involvements  in  the  past,  as  well  as  the  j)i"esence  of 
scars,  deformities  or  sinuses,  is  suggestive. 

Urine. — The  urine  in  tuberculosis  of  the  kidney  at  times  gives  no  indi- 
cation of  the  disease  to  the  casual  observer  until  it  becomes  purulent  and  then, 
if  bladder  symptoms  are  present,  it  may  point  to  a  cystitis  rather  than  to  the 
kidney. 

The  urine  of  tuberculosis  of  the  kidney  may  be  divided  into  three  varieties : 
That  of  the  stage  of  invasion,  of  development  and  of  destruction. 

During  the  period  of  invasion,  the  urine  resembles  that  of  renal  congestion 
of  varying  degrees.  It  may  show  albumin,  red  and  white  blood  cells,  renal  and 
pelvic  epithelia,  hyaline  casts  and  a  variable  specific  gravity. 

During  the  stage  of  development,  w^hich  corresponds  to  that  of  formation 
of  tubercular  foci  and  their  caseation,  together  with  an  increase  of  interstitial 
tissue,  the  urine  resembles  more  that  of  an  interstitial  nephritis ;  that  is,  a 
lai'ger  quantity,  of  a  lower  specific  gravity,  with  a  trace  of  albumin,  a  few  hya- 
line casts  and  renal  epithelia. 

During  the  stage  of  destruction,  after  a  secondary  infection  by  pus-produc- 
ing germs  has  taken  place,  the  urine  resembles  that  of  nephritis  plus  pus ;  that 
is  to  say,  it  is  light  in  color,  of  a  low  specific  gravity  and  may  contain  renal 
epithelia,  pus,  hyaline,  granular,  epithelial  and  pus  casts  and  tubercle  bacilli. 
As  tuberculosis  of  the  kidney  is  so  frequently  associated  with  a  similar  condi- 
tion of  the  bladder,  pus,  blood  and  vesical  epithelia  coming  from  that  organ 
may  be  also  added  to  the  general  urine. 

The  urine  sent  to  the  laboratory  during  the  stage  of  development  of  renal 
tuberculosis  will  generally  be  diagnosticated  as  that  of  interstitial  nephritis; 
or  if  a  cystitis  is  present,  as  cystitis  and  interstitial  nephritis.  No  search  for  the 
tubercle  bacilli  will  be  made  unless  especially  requested.     Again  in  this  stage, 


538  TUBERCULOSIS    OF    THE    KIDNEY 

if  a  search  for  the  tubercle  bacillus  be  made,  it  probably  will  not  be  found,  as 
its  demonstration  is  exceedingly  difficult  unless  the  kidney  is  in  the  suppurative 
stage. 

When  the  suppurative  stage  has  set  in,  the  diagnosis  from  the  laboratory 
often  comes  back  as  cystitis  and  pyelo-nephritis.  It  is,  therefore,  very  im- 
portant in  sending  urine  to  a  urinologist  to  accompany  it  by  a  short  clinical 
history,  stating  that  tuberculosis  is  suspected. 

Tubercle  BacilU. — ISTotwithstanding  the  fact  that  there  are  probably 
tubercle  bacilli  in  the  urine,  it  is  extremely  difficult  to  find  them  in  reno-vesical 
tuberculosis.  I  have  seen  typical  tuberculous  ulcers  in  the  bladder,  Avith  in- 
volvement of  both  kidneys,  and  yet  no  tubercle  bacilli  could  be  found  by  some 
of  the  best  jSTew  York  urinologists  until  several  examinations  had  been  made. 
It  is  very  important  to  have  the  tubercle  bacillus  differentiated  from  the 
smegma  bacillus,  as  it  is  extremely  disheartening  after  specimens  have  been 
examined  for  many  days  at  a  considerable  expense  to  the  patient,  to  have  a 
laboratory  man  say  that  he  has  found  some  bacilli  closely  resembling  tubercle 
bacilli,  but  that  they  may  be  smegma  bacilli.  While  the  morphological  dis- 
tinction between  the  two  is  not  easy,  the  identity  of  the  tubercle  bacillus  can  be 
usually  established  by  treating  with  alcohol  a  specimen  stained  with  carbol- 
fuchsin.  The  smegma  bacillus  becomes  decolorized,  while  the  tubercle  bacillus 
retains  the  red  stain. 

An  aid  to  the  finding  of  tubercle  bacilli  is  to  produce  artificial  polyuria 
and  collect  the  urine  in  a  large  tapering  beaker,  so  as  to  be  able  to  pour  oif  the 
top  and  to  have  an  abundant  deposit  in  the  narrow  bottom.  Frequent  exam- 
inations should  also  be  made — as  often  as  several  times  a  week  if  necessary. 
In  this  way  it  is  probable  that,  in  eighty  per  cent  of  the  cases  of  tuberculosis 
of  the  kidney,  the  bacilli  will  be  found  in  the  urine.  A  clinical  diagnosis,  hoAv- 
ever,  based  upon  the  findings  already  mentioned  together  with  an  exclusion  of 
other  diseases  whose  symptoms  resemble  renal  tuberculosis,  is  usually  correct 
and  accepted. 

Guinea-pig  Inoculations. — Guinea-pig  inoculations  are  very  important 
and  should  be  resorted  to  as  soon  as  tuberculosis  of  the  kidney  is  suspected,  as 
much  time  is  often  lost  in  making  urinary  examinations.  Patients  also  begin 
to  distrust  their  advisers  if  they  are  made  to  Avait  too  long  for  an  opinion,  be- 
sides Avhich  many  do  not  feel  like  paying  for  the  numerous  urinary  and  cys- 
toscopic  examinations.  I  haA^e  lost  a  number  of  interesting  cases  through 
numerous  examinations  of  the  bladder  and  urine  before  finally  resorting  to 
animal  inoculation,  Avhereas,  if  I  had  used  guinea  pigs  immediately,  I  Avould 
have  knoAAm  quite  as  soon  of  the  presence  of  tuberculosis. 

It  is  said  that  the  pigs  should  be  tested  Avith  tuberculin  before  they  are 
inoculated.  ■  The  inoculation  should  be  performed  with  the  same  antiseptic 
precautions  as  an  operation.     The  hair  should  be  shaA^ed  from  the  abdomen ; 


DIAGNOSIS  539 

the  sediment,  diluted  with  normal  salt  solution,  should  be  injected  into  the 
])pritoneal  cavity,  or,  better  still,  into  the  glands  of  the  groin.  The  gaiinea  pig 
should  be  well  fed  and  weighed  every  few  days.  If  at  the  end  of  six  weeks  the 
animal  is  still  alive,  it  should  be  killed  with  chloroform,  the  autopsy  performed 
and  a  search  for  tubercles  made  in  the  peritoneal,  mesenteric  and  inguinal 
glands. 

Tuberculin  Test. — Final  resort  may  be  had  in  the  tuberculin  test.  Rob- 
ert Koch  prepared  a  fluid  from  cultures  of  the  tubercle  bacillus  which  contained 
the  glycerin  extract  of  the  bodies  of  the  germs.  A  subcutaneous  injection  of 
this  fluid,  at  a  minimum  dose,  j^roduces  fever  if  tuberculosis  exists  in  the  body. 
A  large  dose  may  give  rise  to  a  febrile  reaction  in  health.  While  a  positive 
result  is  a  very  strong  evidence  of  an  active  tuberculous  lesion,  a  negative  result 
is  not  quite  so  valuable,  as  in  a  certain  number  of  old  encapsulated  lesions, 
notably  tuberculous  peritonitis,  a  positive  reaction  does  not  occur  even  after 
quite  large  doses. 

Personally,  I  never  use  the  tuberculin  test. 

The    Cutaneous    and    Ophti-ialmo-keaction     Tests. — The     diagnostic 
methods  recently  proposed  by  Von  Pirquet  and  by  Calmette  are  based  on  the 
local  reaction  that  follows  the  application  of  tuberculin  to  the  skin  in  the  for- " 
mer  and  conjunctiva  in  the  latter  of  tuberculous  individuals.      Opinions  are 
divided  as  to  the  practical  value  and  the  harmlessness  of  these  procedures. 

In  a  general  way,  it  may  be  said  that,  wherever  there  is  a  choice  of  several 
diagnostic  methods,  the  simplest  and  safest  should  always  receive  the  prefer- 
ence.    Animal  inoculations  seem  to  meet  the  indications  most  efficiently. 

Cystoscopy. — Cystoscopy  is  often  of  great  importance  in  the  diagnosis  of 
renal  tuberculosis,  as  a  cj^stoscopic  diagnosis  of  vesical  tuberculosis  points  to 
the  probability  of  renal  involvement.  It  is  said  by  some  that  vesical  tubercu- 
losis is  always  associated  with,  or  secondary  to,  renal  tuberculosis,  and  some 
say  that  the  removal  of  a  diseased  kidney  will  cure  a  vesical  tuberculosis.  This 
I  do  not  believe,  as  my  clinical  experience  has  not  corroborated  it.  In  cases 
of  tuberculous  cystitis,  the  bladder  symptoms  are  often  sufficient  to  mask  com- 
I)lctely  those  of  the  kidney  if  it  is  diseased.  At  other  times,  the  bladder  symp- 
touis  are  very  mild. 

Tuberculous  lesions  about  the  mouth  of  the  ureter  should  make  us  sus- 
picious of  tuberculosis  of  the  kidney  on  that  side ;  in  fact,  so  much  so  that  in 
the  absence  of  all  other  symptoms  and  after  repeated  failures  to  find  the  tubercle 
bacillus  in  the  urines,  I  have  operated  on  kidneys  with  lesions  about  the  ureteral 
mouths  on  that  side  and  found  them  to  be  tuberculous. 

There  is  a  class  of  cystitis  spoken  of  as  hemorrhagic.  These  cases  are 
usually  due  to  tuberculosis  or  tumor ;  nearly  always,  I  believe,  to  the  former  in 
young  people  whose  bladders  are  very  sensitive  and  are  spoken  of  as  contracted. 
The  organ  is,  however,  probably  only  in  a  state  of  spasmodic  contraction,  on 


540  TUBERCULOSIS    OF    THE    KIDNEY 

account  of  being  oversensitive.  It  is  often  impossible  to  cystoscope  such 
bladders  satisfactorily,  as  they  may  not  retain  more  than  an  ounce  of  solu- 
tion, although  they  have  been  quite  capacious  but  a  short  time  before.  Even 
■when  sufficiently  anesthetized  for  any  operation,  they  still  remain  spasmodic. 
A  higher  degree  of  anesthesia  would  relax  the  vesical  spasm,  but  would  be 
dangerous  to  the  life  of  the  patient. 

Uketekal  Cathetekizatiox. — Ureteral  catheterization  by  means  of  a 
catheterizing  cystoscope  is  of  treble  value,  as  in  this  way  we  see  the  condition 
of  the  interior  of  the  bladder,  whether  or  not  tuberculous  lesions  are  present 
and,  if  present,  where  they  are  located.  The  presence  of  both  kidneys  can  be 
determined  and  a  specimen  obtained  from  each,  which  will  allow  us  to  judge 
their  comparative  functional  capacity.  In  case  one  ureter  can  be  catheterized 
and  not  the  other,  although  it  is  possible  to  see  the  ureteral  mouth  and  urine 
coming  from  it,  Ave  can  drain  the  catheterized  kidney  with  the  ureteral  catheter, 
and  the  other  kidney  which  cannot  be  catheterized,  by  leaving  an  ordinary  soft- 
rubber  catheter  in  the  bladder  after  the  cystoscope  has  been  removed  and  the 
bladder  emptied,  and  in  this  way  collect  the  two  specimens.  If  we  cannot  iind 
the  mouth  of  the  second  ureter,  or  if,  on  the  other  hand,  we  can  find  it  and 
the  catheter  will  not  enter  and  no  urine  is  seen  to  come  from  it,  then  an  in- 
cision should  be  made  through  the  loin  on  that  side  to  ascertain  if  there  is  a 
kidney  there  and  to  judge  of  its  condition. 

In  one  case  of  so-called  hemorrhagic  tuberculous  cystitis  in  which  not  suf- 
ficient fluid  could  be  introduced  into  the  bladder  to  see  the  ureters,  even  under 
an  anesthetic,  and  yet  I  could  palpate  a  large  pyonephrotic  kidney  on  the  right 
side  but  could  not  feel  the  left,  I  opened  the  peritoneal  cavity  to  make  sure  of 
the  presence  of  another  kidney  and  palpated  what  appeared  to  me  a  normal 
organ  on  the  left  side  before  performing  nephrectomy  on  the  right.  I  do  not 
believe  that  the  exploratory  laparotomy  was  a  good  surgical  procedure,  how- 
ever, and  in  the  event  of  another  such  case  I  would  make  an  exploratory  lumbar 
incision. 

Sometimes  it  is  difficult  or  impossible  to  see  the  bladder  sufficiently  well  to 
examine  its  walls  and  to  find  the  ureters,  on  account  of  the  turbid  fluid  medium. 
Consequently,  after  the  bladder  has  been  washed  for  some  time  and  the  fluid 
has  become  quite  clear,  if  on  refilling  it  prior  to  the  introduction  of  the  cys- 
toscope, the  contents  are  found  to  be  cloudy  again,  it  points  to  a  hydronejDhrotic 
kidney  on  one  side  that  has  again  emptied  itself.  It  is  well,  therefore,  to  press 
upon  the  kidneys  on  both  sides  in  order  to  squeeze  out  the  residual  urine  and 
then  to  empty  and  refill  the  bladder  quickly  in  order  to  see  the  ureter. 

In  catheterizing  ureters  to  determine  the  condition  and  function  of  each 
kidney,  we  must  note  the  rapidity  with  which  the  urine  flows  from  each  side. 
Each  kidney  should  secrete  about  an  ounce  an  hour,  corresponding  to  twenty-four 
ounces  for  each  twenty-four  hours,  or  forty-eight  for  both.     The  diseased  organ 


DIFFERENTIAL   DIAGNOSIS  541 

often  secretes  more  than  the  healthy  one.  In  one  of  the  cases  in  which  I  per- 
formed nephrectomy,  at  least  three  fourths  of  the  kidney  were  found  to  be 
destroyed,  although  the  organ  had  secreted  four  times  as  much  urine  as  the 
licalthy  one ;  but  the  fluid  coming  from  it  was  composed  principally  of  water 
and  pus,  with  a  very  low  specific  gravity.  If  one  kidney  suddenly  secretes  a 
large  amount  of  turbid  white  urine  after  the  introduction  of  the  ureteral  cathe- 
ter and  the  other  secretes  slowly  a  normal  amount,  it  would  seem  to  show  that 
there  is  renal  retention  on  one  side  and,  consequently,  a  pyonephrosis  accom- 
panied by  considerable  renal  destruction.  In  one  of  my  cases,  three  ounces  of 
turbid  urine  of  a  milky  color  and  low  specific  gravity  escaped  immediately  from 
a  kidney,  the  parenchyma  of  which  was  almost  entirely  destroyed. 

Sometimes  a  large  lump  of  pus  is  seen  hanging  from  the  diseased  ureter  and 
at  other  times  thick  pus  comes  down  slowly  through  the  ureteral  catheter  into 
the  bottle  in  a  semisolid  mass,  showing  that  there  is  practically  no  liquid  se- 
creted on  that  side.  Such  a  condition  is  rare  and  points  to  the  presence  of  a 
nonf  unctionating  kidney  or  one  that  is  'a  fibrous  pus  sac  practically  out  of  com- 
mission, or  to  a  perinephritic  abscess. 

Having  collected  the  amount  of  fluid  from  each  side,  it  should  be  measured, 
its  specific  gravity  taken,  the  amount  of  urea  tested,  the  side  containing  the 
pus  noted,  as  well  as  the  amount,  and  the  quantity  of  albumin,  blood  and  the 
variety  of  casts  considered.  The  urine  from  both  sides  should  be  tested  for 
tubercle  bacilli  and  injected  into  guinea  pigs.  The  character  of  the  urine  from 
the  healthy,  or  relatively  healthy,  side  compared  with  that  of  the  general  urine 
will  give  us  an  idea  if  the  healthier  organ  will  be  able  to  carry  on  the  renal  func- 
tion after  the  removal  of  the  diseased  one.  In  other  words,  we  should  determine 
if  there  is  present  in  the  kidney  to  remain  an  amount  of  normal  renal  tissue 
corresponding  to  one  half  or  one  third  of  the  total  renal  tissue  when  in  good 
health,  before  recommending  the  removal  of  the  diseased  organ. 

The  methods  of  determining  the  renal  function  are  the  same  that  have  been 
considered  in  the  chapter  on  the  Examination  of  the  Kidney. 

Differential  Diagnosis. — The  diseases  for  which  tuberculous  kidney  is  most 
frequently  mistaken  are : 

1.  Renal  calculus. 

2.  Renal  tumor. 

3.  Hemorrhagic  nephritis. 

4.  Suppurative  diseases  of  the  kidney,  due  to  urinary  obstruction  or  to 
acute  infectious  nephritis. 

5.  Movable  kidney. 
0.   Cystic  kidney. 

Renal  Calculus. — Renal  calculus  resembles  this  condition  more  than  any 
other.     The  principal  points  of  differentiation  lie  in  the  history.     On  the  side 


542  TUBERCULOSIS    OF    THE   KIDNEY 

of  calculus  there  may  be  the  presence  of  gout,  rheumatism  or  lithemia  in  the 
individual  or  in  the  family ;  while  the  anamnesis  or  the  family  history  may  be 
in  favor  of  tuberculosis.  In  renal  calculus,  the  lumbar  pain  is  more  severe, 
frequent  and  colicky,  usually  following  ujDon  exercise,  jolting  or  any  muscular 
exertion.  Bladder  pain,  tenesmus  and  frequency  of  urination  are  not  so  often 
present,  as  there  is  usually  no  vesical  involvement.  Abdominal  tenderness  and 
muscular  rigidity  are  less  frequent.  Hematuria  occurs  more  often  after  exer- 
cise and  jolting  and  is  generally  more  marked  than  in  tuberculosis,  whereas 
pyuria  is  usually  not  so  frequent  or  pronounced.  The  loss  of  weight,  strength 
and  appetite  are  not  so  frequent,  so  constant,  nor  so  progressive  as  they  are  in 
renal  tuberculosis.  Fever,  chills  and  sweating  may  occur  as  an  attack  when  the 
stone  blocks  the  ureter  in  cases  of  pyonephrosis,  or  more  continuously  in  pyelo- 
nephritis, but  never  as  constantly  as  in  renal  tuberculosis  after  infection.  The 
urine  may  show  crystals  mixed  with  mucus  and  pus,  but  no  tubercle  bacilli. 
There  would  probably  be  no  evidence  of  inflamed  glands,  joints  or  genitals, 
either  in  the  history  or  in  the  physical'  examination ;  nor  would  there  be  any 
nodular  or  suppurating  lesions  of  the  epididymis  or  prostate. 

Radiography  is  important  in  studying  a  case  of  suspected  renal  tuberculosis 
to  diiferentiate  it  from  renal  calculus,  as  the  two  diseases  resemble  each  other 
so  closely.  In  such  case,  the  findings  of  calculus  by  the  X-ray  would  argue 
against  the  presence  of  tuberculosis,  although  renal  tuberculosis  and  calculus 
do  sometimes  exist  in  the  same  kidney.  In  a  recent  kidney  case  sent  to  me 
as  one  of  calculous  nephritis,  the  patient  had  passed  two  small  calculi  in  his 
urine  some  time  before,  accompanied  by  hematuria  and  slight  renal  colic,  and 
still  complained  of  pain  in  the  loin  on  that  side.  Ulcerations  seen  about  the 
ureteral  orifice  in  cystoscopy,  led  me  to  believe  that  it  was  tuberculous ;  the 
X-ray  examination  was  negative  and  the  guinea-pig  test  showed  the  presence 
of  tubercle  bacilli.  This  was  four  years  ago ;  the  patient  refused  to  submit  to 
an  operation  and  has  been  able  to  carry  on  his  work  since  then.  The  kidney 
is  probably  undergoing  gradual  destruction,  or  the  process  has  stopped. 

It  may,  therefore,  be  said  that  in  a  suspected  case  of  renal  tuberculosis, 
positive  findings  of  calculus  with  the  X-ray  argue  against  renal  tuberculosis ; 
negative  findings  argue  in  favor  of  it.  It  may  also  be  said  that  positive  findings 
Vidth  guinea-jDig  inoculations  in  renal  tuberculosis  correspond  in  importance  to 
positive  findings  with  the  X-ray  in  suspected  cases  of  renal  calculus  in  that 
they  are  both  corroborative  evidence. 

Renal  Tumor. — In  cases  of  renal  tumor,  the  pain  is  less  severe  or  absent. 
Bladder  pain,  tenesmus  and  burning  are  absent,  as  well  as  loin  tenderness  and 
muscular  rigidity.  The  patient  is  usually  over  forty  years  of  age.  Urination 
and  pyuria  are  less  frequent  and  severe.  Hematuria  is  more  frequent  and  more 
severe.  Loss  of  weight  and  appetite  progress  much  more  slowly.  Fever  and 
sweating  are  usually  absent.     The  tumor  is  generally  marked  and  can  be  easily 


DIFFERENTIAL   DIAGNOSIS  543 

outlined.  Varicocele  is  often  present  when  the  tumor  is  situated  on  the  left 
side.  No  tubercle  bacilli  are  found  in  the  urine,  but  fragments  of  tumor  and 
atypical  cells  are  frequently  present  and  blood  cells  are  fairly  constant. 

Hemorrhagic  ISTephritis  (Unilateral). — The  pain  may  be  more  severe, 
moderate  or  absent.  There  are  no  bladder  symptoms,  local  tenderness  or  mus- 
cular rigidity.  There  is  no  frequency  of  urination  and  pyuria  is  absent,  as 
Avell  as  fever,  chills  and  sweating.  Hematuria  varies  in  severity  and  frequency 
in  individual  cases.  Loss  of  weight,  strength  and  appetite  are  not  so  marked, 
and  are  proportionate  to  the  loss  of  blood  and  the  nephritis.  ISTo  tumor  can  be 
felt.  The  urine  shows  merely  the  evidence  of  a  nonsuppurative  nephritis  and 
blood.     Tubercle  bacilli  are  not  present  in  the  urine. 

Suppurative  Diseases  of  the  Kidney. — Such  conditions,  not  occurring 
as  a  complication  of  stone  or  tuberculosis,  are  generally  due  to  an  obstruction 
lower  down  in  the  urinary  tract,  a  stricture,  an  enlarged  prostate,  a  calculous 
cystitis  or  a  vesical  tumor  giving  rise  to  either  an  ascending  or  a  hematogenous 
infection.  The  pain  may  be  the  same  and  the  patient  may  also  run  a  tempera- 
ture and  have  sweats  from  the  renal  sepsis.  The  kidney  may  be  enlarged  and 
tender  on  pressure.  Loss  of  weight,  loss  of  appetite  and  emaciation  may  also 
accompany  it  and  the  urine  may  contain  the  same  inflammatory  products  as 
in  pyelo-nephritis  or  pyonephrosis,  minus  the  tubercle  bacilli.  The  regular 
routine  examination  of  the  urethra,  prostate  and  bladder,  together  with  the 
history  of  the  patient,  will  tell  us  if  the  disease  is  due  to  urethral,  j^rostatic  or 
vesical  involvement.  In  some  cases  of  renal  infection,  the  gonococcus  can  be 
found  in  the  urine  from  the  diseased  kidney  by  ureteral  catheterization,  but 
such  cases  are  rare.  I  have  found  only  four  cases  of  gonorrheal  kidney  com- 
plicating urethritis  in  my  practice  of  twenty  years.  Pyelo-nephritis  resulting 
from  gonorrhea  is  in  almost  every  instance  due,  not  to  the  gonococcus  itself, 
but  to  some  other  pus-producing  germs  that  are  present  in  the  urethra,  and 
occurs  only  when  the  kidney  is  predisposed  to  infection.  Hematuria  is  not  so 
frequent  in  suppurative  disease  of  the  kidney  and  it  is  rarely  that  either  ab- 
dominal tenderness  or  muscular  rigidity  is  as  marked  as  in  certain  tuberculous 
cases. 

Movable  Kidney. — The  pain,  if  present, "is  in  the  loin  and  is  more  severe 
at  times  when  a  Dietl's  crisis  occurs,  while  at  other  times  it  is  less  than  in  renal 
tuberculosis.  Urination  is  less  frequent,  but  it  may  be  irregular  in  such  a  way 
that  the  frequency  is  diminished  and  the  quantity  lessened  when  the  kidney  is 
out  of  place,  if  hydronephrosis  is  present.  It  is  followed  by  a  gush  of  urine, 
increased  in  quantity,  when  the  organ  rights  itself.  There  is  no  hematuria. 
In  the  presence  of  infection  of  the  renal  pelvis,  pyuria  occurs,  but  it  is  usually 
less  severe  than  in  a  case  of  tuberculosis  of  the  kidney.  Loss  of  weight,  strength 
or  appetite  is  not  rapid  or  marked.  Fever,  sweating  and  chills  are  rarely  pres- 
ent, unless  the  kidney  is  infected,  which  is  not  often  the  case.     The  urine  is 


544  TUBERCULOSIS    OF    THE   KIDNEY 

generally  less  changed,  but  it  may  very  closely  resemble  that  of  the  early  stages 
of  development  in  tuberculous  nephritis.  It  rarely  contains  as  much  pus  as  in 
the  last  stages  of  tuberculosis.  The  kidney  can  usually  be  felt  as  movable.  It 
is  generally  not  as  large  as  in  tuberculosis  of  the  kidney,  although  it  may  be 
larger  at  times  if  there  is  retention  of  urine  in  the  organ,  which  condition  is 
rarely  constant.     Tuberculosis  has  been  observed  in  movable  kidneys. 

Cystic  Kidney. — Cystic  kidney  is  usually  larger  when  seen,  more  easily 
outlined  and  more  irregular  in  its  contours  than  tuberculous  kidney.  The  con- 
ditions are  very  rarely  confounded,  as  renal  cysts  are  not  common  and  tuber- 
culous kidneys  resembling  cysts  are  exceptional. 

Treatment. — General  Considerations. — The  general  treatment  of  tuber- 
culosis affecting  the  kidneys  is  that  of  all  tuberculous  conditions,  namely, 
hygienic,  dietetic  and  medicinal.  Patients  may  also  be  sent  to  a  climate  which 
is  particularly  favorable  for  the  disease.  These  measures  are  all  that  can  be 
taken  safely,  if  a  marked  general  tuberculosis  exists,  as  is  often  the  case  when 
the  renal  trouble  is  a  secondary  involvement,  or  if  the  opposite  kidney  is  not  in 
a  fairly  healthy  condition.  The  details  of  the  medical  treatment  will  be  con- 
sidered more  in  detail  after  the  consideration  of  the  surgical  part,  which  is  the 
more  important. 

It  is  said  that  the  ordinary  case  of  renal  tuberculosis  will  live  only  three 
years  after  the  first  well-marked  symptoms,  and  that  the  patient,  if  let  alone, 
will  die  of  cachexia  and  uremia.  I  believe,  however,  that  there  are  many 
patients  suffering  from  renal  tuberculosis  who  recover  without  operation  and 
that,  when  we  are  more  familiar  with  the  disease,  this  will  be  shown  to  be 
true. 

In  looking  back,  we  find  the  following  statements  that  will  give  us  a  better 
idea  of  the  views  on  the  treatment  of  this  disease  during  the  last  twenty  years. 

Epstein,  in  Ziemssen's  Encyclopedia,  1877,  says  that  all  treatment  is  ap- 
parently hopeless. 

In  1885,  Gross  collected  20  cases  of  nephrectomy  for  strumous  kidney  from 
the  literature,  in  which  there  were  12  recoveries  and  8  deaths.  In  6  of  the 
cases,  but  one  kidney  was  involved.  In  cases  in  Avhich  nephrotomy  was  pre- 
viously performed,  it  had  been  of  no  benefit,  so  he  advised  immediate  nephrec- 
tomy whenever  possible. 

In  1891,  Madelung  collected  60  cases  of  nephrectomy  from  the  literature. 
He  concludes  that  the  operation  is  indicated  when  the  process  is  to  be  found 
only  in  one  kidney. 

Willy  Meyer,  in  1896,  said  that  a  tuberculous  kidney  was  almost  always  at 
first  unilateral  and  that  the  infection  descended  to  the  bladder.  He  pointed 
out  that  cystoscopy  shows  the  mouth  of  the  affected  ureter  to  be  involved  and 
advocated  the  early  extirpation  of  the  diseased  kidney. 

In  1897,  Senn  recommended  nephrectomy  in  the  case  of  a  tuberculous  kid- 


TREATMENT  545 

iiey  when  the  surgeon  can  prove  the  presence  of  a  healthy  organ  on  the  other 
side. 

In  1904,  Kronlein  said  that  he  regarded  nephrectomy  for  tuberculosis  of 
the  kidney  as  one  of  the  most  successful  operations  in  surgery. 

Bevan,  in  1907,  wrote  that  tuberculosis  of  the  kidney  occurs  primarily  in 
one  kidney  in  ninety  per  cent  of  the  cases  and  that  it  is  the  duty  of  the  general 
practitioner  to  diagnosticate  the  cases  early  and  for  the  surgeon  to  operate 
them  early,  as  a  timely  operation  holds  out  a  good  prospect  for  a  cure. 

According  to  Israel,  early  operations  are  the  keynote  to  a  successful  out- 
come after  an  early  diagnosis  and  have  diminished  the  mortality  more  than 
the  functional  tests,  etc. 

Rovsing  insists  that  every  tuberculous  kidney,  no  matter  how  limited,  re- 
quires removal  of  the  organ,  as  long  as  the  other  kidney  is  healthy. 

Kelly  says  that  no  time  should  be  lost  with  expectant  treatment.  He  favors 
the  removal  of  the  kidney  whenever  possible,  but  he  incises  the  kidney  some- 
times before  removing  it.  The  ureter  is  removed  down  to  the  bladder,  or  per- 
haps with  a  piece  of  the  bladder  wall. 

Yon  Bergmann  says  that  the  kidney  should  be  removed  whenever  tubercu- 
losis is  found.     Bilateral  infection  he  considers  as  very  rare. 

With  this  array  of  evidence  it  would  seem  that,  in  almost  all  cases  of  renal 
tuberculosis,  one  kidney  is  primarily  involved,  and  that  the  only  way  to  save 
the  patient  is  to  remove  the  diseased  kidney  before  the  other  side  becomes 
affected. 

Kronlein  and  Israel  found  that  but  3  per  cent  of  cases  of  renal  tuberculosis 
were  bilateral,  while  Von  Bergmann  found  both  kidneys  involved  in  but  1.9 
per  cent ;  yet  in  postmortems  it  is  found  that  over  60  per  cent  of  the  cases  are 
bilateral.  Such  discrepancies  can  only  be  accounted  for  on  the  ground  that  one 
kidney  is  involved  first  and  the  process  is  sufficiently  far  advanced  to  be  de- 
tected before  the  other  has  become  affected ;  that  one  diseased  kidney  but  not 
the  other  is  far  enough  advanced  to  allow  the  diagnosis ;  or,  in  autopsy  cases, 
tliat  the  patients  died  because  no  operation  had  been  performed  until  both  kid- 
neys had  become  sufficiently  diseased  to  cause  death.  I  may  say  here  that  some 
of  the  best  specimens  of  advanced  renal  tuberculosis  that  I  have  seen  were  at 
the  autopsies  of  cases  dying  of  pulmonary  tuberculosis  in  which  there  had  been 
no  subjective  symptoms  of  renal  trouble. 

I  believe  that,  in  a  large  percentage  of  the  kidneys  removed,  the  other  kid- 
ney is  involved,  but  that  the  involvement  is  not  sufficiently  advanced  at  the 
time  for  us  to  find  tubercle  bacilli  unless  animal  inoculation  is  resorted  to, 
which  in  the  past  has  been  little  practiced.  If  guinea-pig  inoculations  with 
the  urine  from  each  kidney  are  not  made,  we  must  rely  principally  on  our 
urine  analysis  and  functional  tests  to  determine  the  condition  of  the  second 
kidney. 


546  TUBEECULOSIS    OF   THE   KIDNEY 

Operations  are  contraindieated  in  patients  with  diabetes,  weak  heart,  dis- 
eased arteries,  marked  general  tnbercnlosis,  or  when  the  other  kidney  is  in- 
volved ;  bnt  are  indicated  in  patients  w^ith  tubercnlar  bladders,  which  can  be 
treated  locally. 

Operative  Treatment, — The  surgical  treatment  of  renal  tuberculosis  con- 
sists of  the  following  procedures :  Nephrotomy,  nephrostomy  and  partial  or 
total  nephrectomy.  Sixty-seven  per  cent  of  my  cases  were  operated  on;  the  re- 
mainder either  refused  operation  or  were  not  considered  favorable  for  surgical 
interference.  ISTephrectomy  is  the  operation  of  choice  and  should  always  be 
advised  if  the  other  kidney  can  carry  on  successfully  the  renal  function.  Most 
of  my  cases  were  operated  on  by  nephrectomy. 

Nephrotomy  may  be  performed  for  drainage  purposes  in  cases  of  renal  re- 
tention of  pus  and  urine  and  in  cases  of  pyelo-nephritis  with  abscess  formation. 
It  may  be  followed  later  by  nephrectomy,  provided  the  other  kidney  function- 
ates sufficiently  to  allow  the  removal  of  the  diseased  organ.  If,  however,  after 
the  pus  has  been  evacuated  from  the  tuberculous  kidney  and  it  has  been  drained 
for  a  few  days,  its  fellow  is  found  not  to  functionate  sufficiently  well  to  allow  a 
secondary  nephrectomy,  the  wound  should  be  allowed  to  close  again.  In  my 
own  experience,  it  is  comparatively  rare  for  a  leakage  from  tuberculous  kid- 
neys through  the  loin  to  stop  quickly  after  a  nephrotomy.  In  fact,  the  sinuses 
usually  exist  for  a  long  time. 

It  may  be  said  that,  whereas  nephrotomy  is  not  as  dangerous  to  life  at  the 
time  as  nephrectomy,  it  is  not  as  good  a  procedure  for  a  final  recovery. 

Nephrostomy  is  the  operation  of  nephrotomy  plus  suturing  the  sides  of  the 
kidney  to  the  loin  incision.  This  has  its  advantages  and  disadvantages  in  tuber- 
culosis. The  advantage  is  that  the  opening  in  the  kidney  is  directly  beneath 
the  incision  and  therefore  the  treatment  of  the  diseased  organ  locally  is  more 
easily  performed  than  when  the  kidney  is  allowed  to  return  into  its  fossa,  which 
is  partially  beneath  the  ribs.  The  disadvantage  of  nephrostomy  is  that,  after 
the  organ  has  been  fastened  to  the  abdominal  wall,  there  may  be  a  leakage  of 
urine  and  pus  into  the  perirenal  tissues  between  the  edges  of  the  kidney  and 
those  of  the  incision  that  cannot  be  estimated  without  cutting  the  sutures  or 
tearing  away  the  kidney  from  its  new  position.  It  is  easy  to  fix  the  kidney  suc- 
cessfully in  a  clean  case,  but  more  difficult  when  considerable  pus  is  present. 
In  the  majority  of  cases  in  which  the  kidney  is  opened  and  drained,  a  sec- 
ondary nephrectomy  is  necessary.  It  very  often  happens,  however,  that  a 
patient  who  will  not  permit  of  an  immediate  removal  of  the  organ,  will  first 
consent  to  a  nephrotomy,  which  will  give  temporary  relief,  and  later  to  a 
nephrectomy.  With  this  end  in  view,  it  may  be  said,  therefore,  that  it  is  bet- 
ter to  perform  a  nephrostomy  than  a  nephrotomy,  for  then  in  the  case  of  a 
secondary  nephrectomy,  we  will  have  better  command  of  our  kidney,  which  has 
previously  been  brought  into  the  operative  field. 


TEEATMENT  547 

Partial  nephrectomy  may  be  employed  when  but  one  jDole  of  the  kidney  is 
diseased.  This  is  not  a  practical  operation,  as  it  is  extremely  difficult  to  judge 
of  the  degree  of  the  involvement  by  simply  cutting  down  on  an  organ  which  is 
infiltrated  with  tuberculosis,  or  even  by  making  an  incision  through  such  an 
organ,  as  the  hemorrhage  is  always  excessive  and  inspection  of  the  interior  of 
the  kidney  is  difficult.  Again  partial  nephrectomy  is,  to  my  mind,  a  very  serious 
operation  on  account  of  the  amount  of  blood  the  patient  loses.  It  is  necessary 
in  such  cases  to  cut  through  a  portion  of  the  pole  of  the  organ  very  close  to  the 
pedicle  and  at  a  point  at  which  the  blood  vessels  are  large  and  very  difficult  to 
control.  Besides  this,  a  considerable  amount  of  pressure  is  exerted  on  the 
healthy  tissues  by  the  sutures  in  drawing  the  wound  together  and  this  might  cut 
the  renal  tissue  instead  of  holding  it. 

Nephrectomy  is,  then,  the  only  radical  operation  for  the  cure  of  renal  tuber- 
culosis, provided  the  disease  is  unilateral.  There  are  certain  points  to  be. con- 
sidered in  the  operation,  namely,  the  position  of  the  patient,  the  incision,  the 
treatment  of  hemorrhage  that  may  occur,  the  handling  of  the  ureter,  the  dis- 
position of  the  fatty  capsule,  the  closing  of  the  wound,  the  question  of  drain- 
age, besides  the  immediate  dangers  resulting,  such  as  shock,  hemorrhage,  sepsis, 
peritonitis,  as  well  as  the  more  remote  one  of  a  fi^stula. 

The  position  of  the  patient  depends  upon  the  incision  in  nephrectomy  as 
well  as  in  nephrotomy.  The  incision  should  be  free,  which  would  require  the 
patient  to  be  either  on  his  back  or  on  his  healthy  side.  Probably  ninety-five  per 
cent  of  the  patients  operated  on  are  placed  on  the  healthy  side  and  the  incision 
made  is  either  curved  or  oblique,  usually  the  former.  In  either  case,  the  in- 
cision in  the  muscular  wall  begins  at  the  outer  side  of  the  erector  spinge  muscle, 
just  below  the  twelfth  rib.  If  curved,  it  is  continued  downward  and  outward 
along  this  muscle  until  it  approaches  the  crest  of  the  ileum,  when  it  is  curved 
toward  the  anterior  superior  iliac  spine ;  in  the  case  of  the  oblique  incision,  it 
is  parallel  to  the  twelfth  rib  throughout  its  entire  extent.  The  curved  incision 
is  the  one  that  I  am  in  the  habit  of  using  and  is  the  more  popular  method. 
Sometimes,  on  cutting  through  the  abdominal  wall,  pus  is  found,  showing  that 
a  tuberculous  abscess  has  discharged  through  the  external  capsule.  In  fourteen 
per  cent  of  the  cases  that  I  operated,  there  was  pus  outside  of  the  kidney,  peri- 
nephritic  abscesses,  in  nearly  all  of  which  the  opening  of  the  abscess  in  the  kidney 
could  be  detected. 

In  some  of  my  nephrectomy  cases,  there  were  very  dense,  adherent  and 
thick  infiltrations  into  the  leaflet  of  the  perirenal  fascia,  so  that  it  had  to  be 
clamped  and  ligated  in  several  places  before  the  pedicle  could  be  reached.  There 
IS  a  great  difference  in  the  amount  of  bleeding  in  patients,  but  if  ligatures  are 
placed,  by  means  of  the  needle,  before  removing  the  clamp  and  before  cutting 
through  the  dense  tissues  above  and  below  the  kidney,  it  would  be  much  lessened. 
The  adhesions  with  surrounding  tissues  can  often  be  broken  up  more  easily  and 


548  TUBEKCULOSIS    OF    THE   KIDNEY 

the  hemorrhage  lessened  hj  occasionally  pouring  in  peroxid  of  hydrogen.  In 
case  the  capsula  propria  of  the  kidney  and  the  fatty  capsule  are  fused  together 
to  such  a  degree  that  they  cannot  be  separated,  it  is  well  to  do  a  subcapsular 
nephrectomy,  peeling  off  both  capsules  together  from  the  kidney  parenchyma. 
(See  Subcapsular  iSI^ephrectomy. )  Having  brought  the  organ  well  down,  the 
appearance  of  the  kidney  and  ureter  should  be  noted.  Xodules  on  the  kidney 
or  abnormally  soft  areas  indicate  tuberculosis  or  stone,  with  pus  cavities.  Thick- 
ening of  the  ureter  is  always  a  sign  of  tuberculosis  of  the  kidney,  as  are  clus- 
ters of  tubercles  under  the  capsula  propria. 

Aspiration  of  the  Kidney. — If  the  organ  is  found  to  be  full  of  pus  after  it 
has  been  made  freely  accessible,  it  may  be  manijDulated  more  easily  by  aspirat- 
ing the  pus  cavity  and  allowing  the  pus  to  flow  out  through  a  tube  over  the  side 
of  the  patient  into  a  pus  basin. 

Treatment  of  the  Ureter. — When  the  kidney  is  brought  out  of  its  abdominal 
cavity,  hanging  by  its  ureter,  the  question  arises  as  to  the  best  method  of  sever- 
ing it  from  its  attachment.  The  kidney  is  usually  the  original  seat  of  tuber- 
culosis of  the  urinary  tract,  the  infection  traveling  down  the  ureter  to  the  blad- 
der in  many  cases,  and  consequently  it  is  important  to  remove  as  much  of  the 
duct  as  is  diseased.  I  have  been  in  the  habit  of  placing  two  ligatures  a  short 
distance  below  the  pelvis,  cutting  between  the  two  and  thus  separating  the  kid- 
ney, cauterizing  with  pure  carbolic  acid  the  end  of  the  divided  ureter  that  is  to 
remain,  then  treating  it  with  alcohol  and  either  returning  it  to  the  abdominal 
cavity  or  else  attaching  it  to  the  incision.  The  latter  procedure  is,  I  believe, 
preferable,  as,  in  case  the  ureter  does  not  drain  well  into  the  bladder,  and  there 
is  retention  of  pus  in  it,  the  wound  can  be  reopened  and  it  will  be  more  easily 
found.  Many  advocate  removing  as  much  as  possible  of  the  ureter.  Some  are 
still  more  radical  and  say  that  the  duct  should  be  removed  down  to  the  bladder, 
or  even  together  with  a  piece  of  the  bladder  wall.  In  removing  large  portions 
of  the  ureter,  it  is  necessary  to  make  correspondingly  large  incisions,  or  else 
to  make  another  incision  independent  of  the  one  in  the  loin,  farther  down  in 
the  groin,  or  just  above  the  pubes  on  one  side  or  the  other.  This  is  especially 
true  in  males ;  whereas,  in  the  female,  the  incision  can  be  made  on  the  inside 
of  the  dome  of  the  vagina  to  one  side  of  the  cervix  and  the  ureter  caught 
with  a  hook  through  this  incision  just  as  it  enters  the  bladder.  It  can  be  pulled 
down  into  the  vaginal  cavity,  ligated,  cut  through  (Kelly  method)  and  removed 
in  its  entirety  by  this  route  or  else  by  pulling  it  through  the  kidney  incision. 

Personally,  I  have  never  fished  the  ureter  down  through  the  vagina,  but  I 
have  been  told  by  my  colleagues  who  have  performed  this  operation,  that  it  is 
comparatively  easy.  I  have  at  times  felt  tuberculous  ureters  through  the  vagina, 
as  they  are  often  very  much  thickened.  In  any  case,  before  resorting  to  such 
a  procedure,  it  would  be  well  to  introduce  a  ureteral  catheter,  as  this  imparts 
a  firmer  feel  to  the  canal  and  consequently  aids  in  detecting  it.     Until  I  begin 


TEEATMENT 


549 


to  have  more  serious  trouble  with  the  ureters  after  removing  the  kidney,  I 
shall  continue  to  ligate  and  cut  through  them  just  above  the  lower  end  of  my 
incision  in  the  loin  and  fasten  the  end  to  the  lumbar  fascia,  in  which  case  they 
usually  atrophy  and  give  rise  to  no  further  trouble. 

In  nephrectomy,  the  great  danger  to  life  must  be  considered  and  it  is  better 
to  do  an  incomplete  operation  quickly  when  the  patient's  condition  is  not  good, 
than  a  more  radical  one  that  may 
result  in  death.  I  had  one  unfor- 
tunate experience  that  led  me  to 
consider  the  importance  of  sub- 
capsular nephrectomy.  I  had  loos- 
ened the  kidney  from  the  combined 
internal  and  external  capsules, 
Avhich  were  adherent  to  one  anoth- 
er, and  I  could  have  done  a  subcap- 
sular nephrectomy  in  a  few  min- 
utes. I  thought,  however,  that  it 
would  be  wiser  to  remove  the  kid- 
ney with  its  capsule,  which  was 
also  involved,  than  to  leave  the 
united  capsules,  l^umerous  diffi- 
culties were  encountered  from  the 
bleeding  points  and  it  required 
time  to  check  the  hemorrhage.  The 
bleeding  from  the  pedicle  also  re- 
quired clamps  and  packing.  The 
patient  lost  a  considerable  amount 
of  blood  and  died  from  shock  in  a 
few  hours,  whereas  his  life  would 
probably  have  been  saved  had  I 
performed  a  subcapsular  opera- 
tion. Fig.  317  shows  the  kidney  as  it  appeared  some  time  after  removal.  The 
operation  was  a  secondary  nephrectomy  following  a  former  nephrotomy. 

Treatment  of  the  Fatty  Capsule. — This  is  another  important  consideration 
in  operating  on  tuberculous  kidneys.  In  separating  the  fatty  capsule  from  the 
capsula  propria,  we  often  see  superficial  clusters  of  tubercles,  which  are  break- 
ing down  and  undergoing  a  suppurative  process,  that  are  adherent  to  the  fatty 
capsule.  Sometimes  the  covering  of  these  clusters  is  torn  away  with  the  fatty 
capsule,  in  which  case  there  is  a  tuberculous  process  left  in  the  adipose  tissue, 
and  a  septic  process  if  pus-producing  germs  are  present.  The  fatty  cap- 
sule is  involved  in  a  number  of  cases,  and  if  the  kidney  is  removed  the  tuber- 
culous process  may  continue  in  this  tissue.     It  is  therefore  advisable  in  all  of 


Fig.  317. — A  Vertical  Section  of  a  Tuberculous 
Kidney  Removed  by  a  Secondary  Nephrectomy 
WITH  A  Fatal  Result.  Note  the  fused  capsules 
and  the  mass  of  thickening  of  the  renal  tissue. 
There  is  no  sign  of  normal  kidney  tissue  and  the 
organ  was  much  thickened.      (Author's  case.) 


550  TUBEECULOSIS    OF    THE   KIDNEY 

these  eases  to  remove  as  nnicli  of  the  fatty  capsule  as  we  can  and  then  to  wash 
out  the  cavity  with  peroxid  of  hydrogen. 

Closing  of  the  wound  after  a  nephrectomy  for  tuberculosis  is  another  im- 
portant consideration.  I  see  no  reason  why  it  should  not  be  closed  if  no  pus 
has  been  fomid  in  the  urine  coming  from  that  side  on  ureteral  catheterization 
nor  during  the  operation.  Again,  if  there  is  pus  present  in  the  urine  or  wound, 
and  the  ureter  has  been  doubly  ligated,  cut  through  between  the  ligatures  and 
its  ends  cauterized,  I  see  no  reason  why  the  wound  should  not  be  closed  after 
washing  out  the  renal  fossa  with  a  solution  of  bichlorid  of  mercury  or  with 
peroxid  of  hydrogen.  In  case,  however,  that  there  are  adhesions  between  the 
surrounding  tissues  and  the  suppurative  areas  on  the  surface  of  the  organ,  or 
a  kidney  abscess  breaks  during  the  manipulations  required  for  its  removal,  or 
if  in  any  way  pus  enters  the  renal  fossa,  it  is  advisable  to  put  a  drain  down 
to  the  site  of  the  kidney.  If  drainage  is  inserted  as  a  precaution  when  we  con- 
sider that  we  have  cleaned  our  field  thoroughly,  it  should  be  removed  at  the  end 
of  twenty-four  or  forty-eight  hours ;  for  if  it  is  left  for  two  or  three  days,  it  tends 
to  induce  suppuration. 

In  cases  in  which  the  wound  is  packed  with  gauze  after  the  operation,  the 
removal  of  it  sometimes  causes  an  elevation  of  the  temperature. 

Treatment  of  Perinephritic  Abscess. — In  case  of  tuberculosis  of  the  kidney 
being  associated  with  perinephritic  abscess,  we  should  be  satisfied  with  evacuat- 
ing the  abscess,  examining  the  pus  cavity  and  draining  it  at  the  first  operation. 
When  the  relations  of  the  kidney  have  been  reestablished,  further  operative  pro- 
cedures can  be  carried  out  later  on.  This  was  contrary  to  my  belief  some 
time  ago,  when  I  thought  it  advisable  to  do  as  much  as  possible  at  the  first 
operation. 

After-treatment  of  Nephrectomy. — In  the  event  of  a  profuse  hemorrhage  at 
the  time  of  the  operation,  we  should  give  one  thirtieth  of  a  grain  of  str^'chnin  hy- 
podermically  and,  in  case  the  pulse  is  rapid  and  weak,  saline  intravenous  should 
also  be  given.  If  there  has  not  been  much  hemorrhage,  but  sufficient  to  lead  us 
to  think  that  shock  may  follow,  it  is  well,  in  addition  to  the  hypodermic  of 
strychnin,  to  administer  a  pint  of  hot  saline  with  two  ounces  of  whisky  by 
enema  as  soon  as  the  patient  is  put  to  bed.  After  this,  a  pint  of  hot  saline 
without  the  whisky  and  one  thirtieth  of  a  grain  of  strychnin  can  be  continued 
every  four  hours,  alternating  so  that  the  patient  will  have  one  or  the  other  every 
hour  until  the  pulse  is  satisfactory  and  the  danger  of  shock  has  passed. 

Temperature  after  Operation. — After  operation,  my  patients  ran  a  tem- 
perature of  from  100°  to  101°  F.,  and  the  pulse  ranged  from  90  to  100  in 
favorable  cases,  becoming  normal  in  from  three  to  seven  days.  In  other  pa- 
tients, the  temperature  ran  from  101°  to  105°  plus  F.,  and  the  pulse  from  120 
to  140.     The  cases  with  high  pulse  and  high  temperature  usually  did  badly. 

The  patient's  bowels  are  usually  moved  on  the  second  day  after  operation 


TKEATMENT  551 

hy  luagnesiuni  sulpliato  followed  by  a  soapsuds  enema.  If  the  Ijowels  do  not 
move  on  the  following  day,  compound  cathartic  pills  are  given. 

The  amount  of  urine  passed  the  first  day  after  operation  averaged  one  pint, 
and  from  forty  ounces  upward  after  this. 

Salt  solution,  was  given  to  patients  developing  uremia,  by  enteroclysis  or 
hyjiodcrmoclysis,  and  some  were  bled,  this  being  followed  by  a  saline  infusion. 
Uremia  occurring  immediately  after  operation  is  of  very  bad  augury. 

Complications. — Peritonitis  is  a  very  rare  complication,  but  may  occur  if 
the  peritoneum  has  been  torn  through  at  the  time  of  the  operation.  I  have  had 
this  accident,  but  it  was  never  accompanied  by  peritonitis,  I  simply  washed 
with  salt  solution  and  closed  the  tear  with  catgut. 

Sepsis,  depending  upon  infection  of  the  renal  fossa,  requires  prompt  and 
thorough  measures  for  its  removal.  If  the  wound  has  already  closed,  it  must 
be  reopened  and  the  pus  pockets  must  be  carefully  sought  for  and  drained, 

Si7iuses  frequently  occur  in  septic  cases  and  are  very  difficult  to  cure.  Those 
due  to  a  silk  ligature  will  close  when  the  ligature  is  removed.  A  sinus  caused 
by  infection  persists  for  a  long  time.  The  walls  of  sinuses  in  these  cases  are 
often  covered  with  tubercles,  which  are  treated  by  curetting;  swabbing  with 
carbolic  acid  and  alcohol ;  packing  with  iodoform  or  balsam-of-Peru  gauze.  At 
times  they  are  very  obstinate,  and  the  w^ound  may  not  close  for 'weeks.  The 
chromic-gut  sutures  in  the  muscular  wall  and  skin  sometimes  give  way  and 
there  is  a  wide  gap  in  the  loin  into  which  several  fingers  can  be  introduced. 
In  such  cases,  there  are  usually  tuberculous  deposits  along  the  sides  of  the 
wound.  The  presence  of  a  sinus  tends  to  keep  the  patient  below  par  through 
a  certain  amount  of  pus  absorption.  The  longest  period  that  a  tuberculous  sinus 
existed  among  my  cases  was  for  nine  years  following  a  nephrotomy,  when  it 
gradually  healed.  After  one  nephrectomy  there  was  a  gaping  wound,  wdth  a 
tuberculous  process  on  its  sides  for  six  months.  It  w^as  dressed  with  iodoform 
and  balsam-of-Peru  gauze,  irrigated  with  silver  and  bichlorid  and  even  swabbed 
with  carbolic  and  alcohol,  with  no  effect.  The  wound  w^as  kept  strapped  and 
eventually  healed,  I  believe  that,  in  certain  cases  after  a  nephrotomy  or  the 
opening  of  a  perinephritic  abscess,  the  tuberculous  process  may  continue  in  the 
organ  until  it  has  become  completely  destroyed,  w'hen  the  sinus  will  close, 

EesuUs. — Among  my  patients,  death  in  the  first  few  days  after  nephrec- 
tomy was  due  either  to  shock,  asthenia,  anuria,  or  uremia,  in  ten  per  cent  of 
my  cases.  In  some  of  the  fatal  cases,  it  has  been  interesting  to  learn  from 
autopsy  that  the  patient  could  not  have  recovered  on  account  of  the  condition 
of  the  other  kidney  and  yet  the  tests  for  the  renal  function  appeared  favorable, 
while  the  acute  infectious  process  in  the  diseased  kidney  was  so  alarming 
that  it  seemed  that  the  organ  should  be  removed  as  an  emergency  operation. 
Such  cases  should,  I  think,  have  been  treated  by  nephrotomy  and  drainage,  and 
a  secondary  nephrectomy.    On  the  other  hand,  there  were  certain  cases  in  which 


552  TUBERCULOSIS   OF   THE   KIDNEY 

the  renal  fimction  tests  and  the  signs  of  tuberculosis  elsewhere  were  so  unfavor- 
able, that  I  told  the  patients  that  I  thought  the  result  of  a  nephrectomy  would 
be  fatal,  whereupon  they  went  to  other  operators  who,  without  testing  the  renal 
■function,  operated  with  a  successful  outcome. 

In  one  case,  the  patient's  only  kidney  was  removed,  but  this  was  in  the  days 
before  we  employed  ureteral  catheterization  in  the  hosj^ital.  I  have  gained 
much  experience  from  my  mistakes  in  early  cases,  and,  although  I  was  then 
doing  what  was  considered  right,  I  now  see  that  my  course  was  wrong  and  I 
have  learned  to  realize  the  importance  of  studying  each  case  carefully  myself 
instead  of  relying  on  the  opinions  and  examinations  of  others.  The  above- 
mentioned  case  has  been  a  lesson  to  me  never  to  remove  a  kidney  until  all  my 
customary  routine  examinations  have  been  made  by  myself  and  my  associates. 
Many  of  my  patients  have  gone  to  other  surgeons  on  account  of  my  insisting 
upon  this,  but  my  mortality  statistics  have  been  greatly  improved  by  my  refusal 
to  operate  them. 

Nonfunctionating  or  Derelict  Kidneys. — One  kidney  can  sometimes  be  de- 
stroyed while  the  other  carries  on  its  function.  In  one  case  of  unilateral  renal 
tuberculosis,  with  involvement  of  the  bladder,  testes,  prostate  and  seminal  vesi- 
cles in  a  patient  running  but  one  degree  of  temperature  and  not  losing  weight, 
I  am  inclined  to  think  that,  if  no  operation  had  been  performed,  the  kidney 
would  have  been  destroyed  entirely  in  a  short  time  and  the  patient's  condition 
would  have  remained  practically  unchanged.  The  kidney  after  removal  was 
found  to  have  four  fifths  of  its  tissue  destroyed.  I  have  seen  other  kidneys  in 
which  probably  seven  eighths  had  been  destroyed,  and  the  other  kidney  has 
"been  able  to  carry  on  the  function,  after  the  removal  of  its  fellow.  I  have  had 
three  kidneys  in  which  the  entire  parenchyma  had  been  practically  destroyed 
and  which  could  excrete  only  a  little  pus  or  a  small  amount  of  watery  fluid 
containing  pus.  One  of  these  I  removed  at  autopsy.  The  other  two  were  ex- 
tirpated in  operation ;  one  was  a  pyelo-nephritic  kidney,  and  the  outcome  was 
death ;  the  other  was  a  pyonephrotic  kidney  and  the  patient  made  an  unevent- 
ful recovery.  There  are  many  persons  with  one  nonfunctionating  kidney,  a 
large  percentage  of  which  are  destroyed  by  tuberculosis. 

Medical  Treatment. — There  are  a  number  of  patients  suffering  from 
tuberculosis  of  the  kidney  who  must  be  treated  medically.  First,  cases  in  which 
the  disease  is  suspected  and  yet  the  diagnosis  has  not  been  made ;  second,  when 
both  kidneys  are  too  much  involved  to  warrant  the  removal  of  one  of  them; 
third,  in  case  of  patients  wdio  need  the  operation  but  do  not  consent  to  it. 

When  we  are  studying  suspected  cases  of  renal  tuberculosis  and'  before  the 
tubercle  bacillus  has  been  found,  the  patient  should  be  treated  symptomatically, 
and  if  we  think  that  tuberculosis  is  present,  the  same  treatment  should  be  given 
as  if  the  diagnosis  had  already  been  made.  This  is  advisable  for  the  reason 
that,  in  many  cases,  a  number  of  urinary  and  cystoscopic  examinations  have  to 


TEEATMENT  553 

be  made  and  several  days  or  weeks  may  pass  before  the  diagnosis  is  completed 
and  operative  or  other  treatment  decided  upon. 

My  observations  in  the  treatment  of  certain  patients  have  convinced  me  that 
a  nmnber  of  cases  can  be  cured  by  medical  treatment.  In  connection  with  the 
general  treatment  of  the  renal  condition,  advantage  should  be  taken  of  the 
opportunity  to  treat  the  bladder  as  well,  in  case  it  is  involved.  The  treatment 
consists  of  rest,  proper  diet  and  clothing,  fresh  air  and  drugs.  Among  the  last- 
mentioned  we  have  the  so-called  specifics:  Creosote,  guaiacol  and  cod-liver  oil. 
Among  the  tonics  which  are  the  most  useful  are :  Sirup  of  iodid  of  iron,  Bash- 
am's  Mixture  and  strychnin.  The  urinary  antiseptics  that  I  use  are :  urotropin, 
salol  and  benzoate  of  soda. 

Method  of  Life. — The  method  of  life  is  of  great  importance.  The  pa- 
tient should  at  all  times  be  comfortable  and  free  from  worry.  In  case  the  blad- 
der is  involved,  giving  rise  to  great  frequency  of  urination,  pain  and  tenesmus, 
a  rubber  urinal  should  be  worn  during  the  day,  strapped  to  the  leg,  and  a  glass 
urinal  should  be  kept  beside  the  patient  in  bed  during  the  night.  The  ease  and 
relief  that  is  obtained  in  this  way  does  much  toward  his  improvement  and  peace 
of  mind.  As  little  time  as  possible  should  be  devoted  to  business.  The  patient 
should  rest  at  home  in  the  evenings  and  on  damp,  unpleasant  days,  lying  about 
on  a  couch  or  reclining  in  a  comfortable  chair.  In  these  cases,  as  in  those  of 
tuberculosis  of  the  lungs,  fresh  air  and  sunshine  are  of  great  importance ;  there- 
fore, the  patient  should  remain  out  of  doors  as  much  as  possible  when  the  sun 
is  shining.  Exposure  to  draughts  of  air  should  also  be  avoided.  The  body 
should  be  kept  warm,  special  attention  being  given  to  the  legs  and  feet.  Woolen 
underclothing  or  flannels  are  the  most  suitable.  When  out  walking  about,  great 
care  must  be  taken  not  to  perspire  and  then  sit  about  in  the  sweat-soaked  gar- 
ments, but  to  return  home  and  change  the  clothing. 

The  diet  in  tuberculosis  of  the  kidney  should  be  similar  to  that  of  tubercu- 
losis of  the  lungs,  excepting  that  forced  feeding  should  be  avoided.  If  the  patient 
is  very  ill,  a  milk  diet  should  be  given ;  otherwise,  cereals,  eggs,  fish,  meat  and 
green  vegetables  in  moderate  amounts.  Anything  tending  to  interfere  with  diges- 
tion should  be  avoided.  In  fact,  we  may  say  that  the  diet  in  tuberculosis  of  the 
kidney  should  be  a  mixture  of  that  of  the  consumptive  and  that  of  the  nephritic. 

Drugs. — Creosote  and  guaiacol,  the  specifics  in  pulmonary  tuberculosis,  are, 
I  believe,  of  as  much  or  more  benefit  in  tuberculosis  of  the  kidney.  I  am  in  the 
habit  of  using  creosote  carbonate,  three  grains,  three  times  a  day.  Guaiacol  I 
have  used  but  rarely  and  cod-liver  oil  never.  Sirup  of  iodid  of  iron  is,  in  my 
opinion,  the  next  best  remedy  to  creosote  in  such  cases.  I  am  in  the  habit  of 
giving  it  mixed  with  equal  parts  of  sirup  of  bitter  orange  peel,  a  half  to  one 
teaspoonful  to  the  dose,  between  meals,  in  milk  or  water.  Basham's  Mixture 
(mistura  ferri  et  ammonii  acetatis),  two  drachms  three  times  a  day,  is  another 
good  iron  mixture. 


554  TUBERCULOSIS    OF    THE    KIDNEY 

Urotropin  is,  I  presume,  of  great  value  as  a  urinary  antiseptic,  especially 
when  there  is  a  suppurative  process  in  the  tubules  of  the  kidney  and  renal 
pelvis,  as  well  as  in  the  ureters  and  bladder.  It  tends  to  Cfjnvert  the  urine; 
into  an  antiseptic  wash.  Personally,  I  do  not  know  the  exact  benefit  to  be  d(!- 
rived  from  urotropin  in  such  cases  and  think  that  it  would  require  considerable 
study  to  be  able  to  determine  it.  I  only  use  it  in  cases  of  pyonephrosis  with  re- 
tention of  pus.  Benzoate  of  soda,  in  my  practice,  has  been  the  urinary  antiseptic 
best  borne  by  the  patient.     The  exact  relative  value  of  the  two  is  unknown  to  me. 

Bladder  cases  are  relieved  by  antispasmodics,  such  as  belladonna,  codeiu, 
morphin  and  the  bromids.  The  prescription  that  I  usually  give  under  these 
conditions  consists  of  tincture  of  belladonna,  2  drachms,  benzoate  of  soda,  4 
drachms  and  aqua  Gaultheria,  up  to  2  ounces ;  a  teaspoonf ul  three  times  a  day, 
between  meals.  If  this  does  not  relieve  the  pain,  I  add  codein  so  as  to  give 
^  of  a  grain  to  each  dose.  In  many  cases,  this  gives  absolutely  no  relief,  nor  do 
any  of  the  other  remedies  recommended  for  such  conditions,  and  I  have  to  give 
morphin  and  bromid  of  potash.  The  mixture  I  use  in  such  cases  is  composed 
of  morphin,  ^  to  ^  of  a  grain,  and  bromid,  15  grains,  to  the  dose ;  while,  in  cer- 
tain other  cases  that  I  have  had,  this  has  not  been  efficacious  until  I  added  8 
grains  of  chloral  hydrate  to  the  dose.  At  first  I  gave  this  mixture  of  morphin, 
chloral  hydrate  and  bromid  with  some  apprehension  to  patients  "with  tubercu- 
losis of  the  bladder,  when  the  kidneys  w^ere  involved.  It  gave  the  patient  great 
relief,  however,  and  the  urine  examination  showed  no  ill  effects  of  the  medicine 
ujDon  the  kidney. 

There  is  no  need  of  going  into  details  of  the  bladder  treatment  in  the  con- 
sideration of  the  trouble  of  which  we  are  speaking.  I  wall  add,  however,  that 
boric-acid  irrigations  of  the  bladder  have  very  little  effect.  ISTitrate  of  silver 
irritates  the  bladder  as  does  also  bichlorid  of  mercury.  In  these  cases,  after 
bladder  irrigations  with  a  solution  of  nitrate  of  silver,  by  a  very  small  rubber 
catheter  and  a  fountain  syringe,  I  have  found  that  if  an  injection  of  argyrol 
into  the  bladder  is  made  after  the  silver  solution  has  been  allowed  to  run  out, 
the  irritation  following  silver  irrigations  has  been  very  much  relieved.  I  have 
thus  been  able  to  use  from  a  1 :  2,000  to  a  1 :  1,000  solution  of  nitrate  of  silver 
in  the  bladder,  by  injecting  2  or  more  drachms  of  a  10-per-cent  to  a  25-per-ccnt 
solution  of  argyrol  after  the  bladder  had  been  emptied  of  the  silver  solution. 

In  this  way,  I  have  absolutely  cured  tuberculous  bladders  with  ulcerations. 
Gommenol  is  also  a  valuable  remedy,  to  be  injected  (^  oz.)  into  the  bladder  in 
a  strength  of  10  per  cent  to  50  per  cent  and  allowed  to  remain.  Iodoform  emul- 
sion, 2  per  cent  in  strength,  is  also  of  value. 

Strictures  of  the  urethra  should  be  dilated  or  cut.  This  is  of  great  im- 
portance, as  is  also  the  cutting  of  a  narrow  meatus. 

Regarding  the  second  group — the  cases  in  which  both  kidneys  are  too  much 
involved  to  warrant  removal  of  one  of  them — and  the  third  gTOup,  in  which  the 


ILLUSTEATIVE    CASES  555 

patients  who  need  operation  refuse  to  be  operated,  I  would  say  that  they  are 
treated  by  the  same  restorative  and  supportive  measures.  Tliese  patients  should 
be  weighed  carefully  at  frequent  intervals,  and  the  amount  of  pus  voided  should 
be  estimated  often,  as  these  two  measures  serve  as  the  best  guides  in  judging 
the  progress  of  the  disease. 

A  change  of  climate  and  of  surroundings  is  also  valuable  and  the  same 
climates  that  are  of  value  in  tuberculosis  of  the  lungs  are  also  of  value  in  tuber- 
culosis of  the  kidney;  that  is  to  say,  a  dry  equable  climate  where  the  patients 
can  remain  out  of  doors.  I  do  not  think  that  the  cold  of  the  mountains,  such 
as  the  Adirondacks,  is  of  benefit,  but  rather  the  milder  climates  of  Nassau,  Ber- 
muda, and  southern  California.  I  have  a  number  of  patients  at  present,  who 
have  refused  to  be  operated  for  two  or  three  years,  and  who  are  in  the  same 
condition  as  when  they  called  for  an  opinion,  at  which  time  it  was  considered 
advisable  to  operate  upon  them. 

Patients  with  pus  coming  from  both  kidneys,  with  the  bladder  involved  as 
well,  have  also  been  absolutely  cured  by  the  treatment  that  I  have  outlined, 
and  yet  I  consider  it  extremely  dangerous  to  take  chances  with  medical  treat- 
ment and  recommend  nephrectomy  in  all  cases  in  which  one  kidney  is  involved, 
if  the  other  is  absolutely  normal. 

Under  conservative  treatment,  a  few  patients  gained  weight,  but  most  of 
them  lost,  and  this  did  much  toward  leading  them  to  operation.  Some  patients, 
however,  waited  too  long,  until  the  period  when  they  could  be  successfully 
operated  on  had  passed. 

Illustrative  Cases. — Regarding  the  successful  treatment  of  renal  tubercu- 
losis without  operation,  I  will  report  two  cases  which  come  to  my  mind,  whose 
symptoms  closely  resembled  each  other,  as  did  the  course  of  the  disease. 

Case  l^o.  1. — The  first  patient,  a  well-built  real-estate  man  of  healthy  ap- 
pearance, forty-six  years  old,  with  no  venereal  history.  He  began  to  have 
increased  frequency  of  urination  five  months  before  his  visit  to  me,  at  which 
time  he  was  urinating  with  pain  and  tenesmus  every  fifteen  or  twenty  minutes, 
both  day  and  night,  so  that  his  sleep  was  disturbed  and  his  general  condition 
very  much  weakened. 

Examination. — There  Avas  slight  tenderness  in  his  loin,  more  nuirkcd  (^n  the 
left  side.  His  testes  and  epididymis  were  normal,  his  meatus  measured  19 
French.  The  prostate  was  nodular ;  the  vesicles  were  negative.  The  urine  was 
opaque,  of  a  milky  or  starchy  color,  low  specific  gravity;  albumin,  one  quarter 
of  one  per  cent ;  pus,  many  cells  and  in  masses ;  a  few  red  blood  cells ;  cast's, 
hyaline,  granular  and  pus ;  epithelia  from  renal  tubules  and  pelvis,  ureter,  blad- 
der and  prostate.  The  diagnosis  from  the  urinary  examination  at  the  time  w'as 
interstitial  nephritis,  pyelo-nephritis  and  slight  cystitis. 

The  treatment  for  the  frequency  and  tenesmus  was  a  mixture  of  benzoate 
of  soda  and  belladonna ;  hot  sitz  baths  twice  daily.     The  bladder  was  treated 


556  TUBERCULOSIS    OF    THE    KTDXEY 

by  irrigations  with  a  silver  solution,  1 :  8,000  to  1 :  2,000,  hy  catheter,  and  the 
prostate  massaged  every  other  day.  These  measures  failed  to  relieve  the 
patient,  who  continued  to  suffer,  especially  at  night. 

The  following  treatment  w'as  adopted  with  favorable  results:  For  the  pain 
and  tenesmus  and  frequent  urination,  morphin  /;  of  a  grain,  chloral  hydrate  7| 
grains,  bromid  of  potash  15  grains,  in  a  mixture  every  four  to  six  hours.  Uro- 
tropin  10  grains,  three  times  daily.  Creosote  was  also  given  internally,  as  the 
disease  appeared  to  me  to  be  reno-vesical  tuberculosis.  The  bladder  was  washed 
once  daily  with  nitrate-of-silver  solution,  followed  by  half  an  ounce  of  a  twenty- 
five-per-cent  solution  of  argyrol.  A  rubber  urinal  was  worn  during  the  day  and 
the  patient  was  instructed  to  sleep  with  a  glass  urinal  between  his  legs  at  night. 

The  meatus  was  cut  to  32  French.  Sleep  promptly  improved  and  the  pa- 
tient's physical  and  mental  condition  were  appreciably  relieved. 

He  was  cystoscoped  under  ether  and  his  bladder  capacity  proved  one  ounce 
and  a  half.  It  required  three  quarters  of  an  hour  to  obtain  a  sufficiently  clear 
medium  to  look  through,  on  account  of  the  pus  coming  dovm.  from  the  kidneys. 
The  prostatic  base  was  red,  resembling  a  strawberry,  the  redness  extending 
along  the  trigone.  There  was  a  small  ulcer  near  the  mouth  of  the  left  ureter 
and  many  flocculi  were  seen  coming  from  it.  There  was  also  a  typical  tuber- 
culous ulcer  on  the  anterior  wall  of  the  bladder  near  the  sphincter.  Two  small 
bodies  resembling  small  calculi  were  seen  lying  behind  the  trigone ;  but  these 
were  no  longer  visible  at  the  time  of  a  later  cystoscopy.  The  bladder  was  but 
slightly  inflamed.  The  clinical  picture  was  one  of  tuberculosis  of  the  kidney 
with  extension  to  the  bladder ;  but  no  tubercle  bacilli  could  be  found  in  the 
urine,  although  it  showed  the  colon  bacillus,  the  staphylococcus  and  the  strepto- 
coccus. Operative  interference  seemed  to  be  indicated,  but  meanwliile  the 
patient's  condition  was  improved.  The  ureters  were  catheterized  and  an  im- 
pediment was  encountered  in  the  upper  part  of  the  left  ureter.  After  the  cathe- 
ter had  been  pushed  into  the  renal  pelvis,  two  drachms  of  urine  escaped,  of  a 
starchy  color  and  a  low"  specific  gravity  and  containing  a  large  amount  of  pus 
and  mucus,  showing  pyonephrosis  on  that  side.  The  right  ureter  was  not  stric- 
tured  and  there  was  no  renal  retention  on  that  side.  The  condition  was  pyelo- 
nephritis. 

The  patient  had  a  marked  polyuria  ;  there  was  pyonephrosis  of  the  left  kid- 
ney, due,  I  believe,  to  a  partial  destruction  of  that  organ  by  a  mixed  infection 
wath  tubercle  bacilli  and  pus-producing  germs.  The  obstruction  of  the  left 
ureter  could  be  accounted  for  by  a  tuberculous  thickening  or  stricture  and  the 
ulcer  near  the  mouth  of  the  left  ureter  I  believed  to  be  the  result  of  the  descend- 
ing process  through  the  duct.  The  ulcer  on  the  vesical  wall  was  typically  tuber- 
culous, and  the  bladder  was  slightly  inflamed. 

The  condition  in  the  kidney  was  a  much  more  extensive  process  than  that 
in  the  bladder.     Tubercle  bacilli  were  found  in  the  urine  a  few  davs  afterwards. 


TLLITSTRATIVE    CASES  557 

corroborating  the  diagnosis  of  urinary  tubercnlosis.  The  patient  was  kept  un- 
der the  treatment  already  outlined  for  about  one  month  and  was  relieved  of  his 
pain ;  then  he  was  sent  home  to  continue  his  medical  and  hygienic  cure.  His  con- 
dition steadily  improved  and  one  year  later  he  reported  freedom  from  symptoms 
and  absolutely  normal  urine,  excepting  a  slight  deficiency  in  urea.  The  patient 
has  been  seen  repeatedly  since  and  has  continued  in  perfect  health  for  five  years. 

Case  ISTo.  2. — The  second  patient,  whose  history  was  much  shorter  and  more 
involved,  was  an  expressman,  twenty-one  years  old,  about  5  feet  8  inches, 
pale,  thin  and  gaunt,  having  recently  lost  thirty  j)ounds  in  weight.  Five  months 
before,  the  patient  had  urethritis  and  three  weeks  before  frequent  urination  set 
in,  until  urine  was  passed  every  fifteen  to  twenty  minutes,  both  day  and  night, 
with  burning;  and  tenesmus.  The  second  urine  was  white,  turbid,  of  a  starchv 
or  milky  hue ;  at  other  times  it  resembled  rainwater.  His  prostate  was  soft, 
with  the  exception  of  a  nodule  on  the  left  side ;  vesicles  tender.  The  bladder 
held  but  a  few  drachms.  He  w^as  put  upon  the  same  treatment  as  the  first  pa- 
tient and  his  meatus,  Avhich  had  been  17  French,  was  cut  to  No.  33  French. 

The  urine  showed  a  specific  gravity  less  than  1.001,  slightly  acid;  albumin 
15  per  cent  by  bulk  (Heller's  test)  ;  urea  yV  of  1  per  cent;  an  occasional  red 
blood  cell ;  pus,  innumerable  cells,  small  masses  and  pieces  of  pus  casts ;  casts, 
hyaline,  granular  and  pus ;  epithelia,  granular,  renal  and  vesical ;  bacteria, 
gonococci,  colon  bacilli  and  tubercle  bacilli.  The  general  specimens  showed  a 
reno-vesical  tuberculosis.  The  kidneys  were  markedly  involved  pyelo-nephritis. 
The  patient,  under  the  treatment  already  outlined  in  Case  ISTo.  1,  was  im- 
proving slowly  and  gaining  in  strength  and  weight.  Cystoscopy  was  tried, 
but  he  could  not  tolerate  sufficient  fluid  in  his  bladder.  Finally  it  was  per- 
formed under  a  general  anesthetic.  The  bladder  held  at  this  time  three  ounces ; 
it  was  much  congested  about  the  trigone  and  somewhat  inflamed.  Small  ulcera- 
tions were  seen  about  the  mouths  of  the  ureters.  Catheterization  of  the  ureters 
was  performed,  the  catheters  remaining  in  for  one  hour. 

The  examination  of  the  two  specimens  was  as  follows : 

Bight  Left 

Quantity — 27  c.c.  (^vij).  Quantity — 93  c.c.   (oiij). 

Sediment — slight.  Sediment — none. 

Colorless.  Colorless. 

Albumin — -10  per  cent  by  bulk.  Albumin — 25  per  cent  by  bulk. 

Sugar — negative.  Sugar — negative. 

Urea — f  of  1  per  cent.  Urea — -J  of  1  per  cent. 

Indican — ^negative.  Indican — negative. 

Red  blood  cells.  Eed  blood  cells. 

Pus  cells  and  pus  in  masses.  Pus  cells  and  pus  in  masses. 

Casts,  hyaline,  granular  and  pus. 


558  TUBERCULOSIS    OF   THE   KIDNEY 

The  process  liad  been  prineipally  in  the  left  kidney,  and  the  pus,  mixed  easts 
and  pus  casts  formed  had  principally  come  from  this  side. 

The  patient  gained  eleven  pounds  during  the  first  month  and  twenty  during 
the  second.  One  year  afterwards  he  weighed  180  pounds.  The  symptoms  in  his 
case  were  more  acute  than  in  Case  No.  1.  The  polyuria  was  more  marked ;  the 
specific  gravity  and  the  urea  were  less.  The  process  was  much  more  marked 
in  the  kidney  than  in  the  bladder.  There  were  ulcers  about  the  niouths  of 
both  ureters,  showing  a  descending  infection.  The  patient  ran  but  a  slight 
temperature,  however,  never  more  than  100°  F.,  which  was  a  little  more  than 
Case  'No.  1.  He  was  under  treatment  for  two  months  and,  when  he  was  obliged 
to  return  to  bis  home  at  this  time,  his  condition  was  much  improved.  He  could 
hold  his  urine  an  hour  or  more  during  the  day  and  only  urinated  four  or  five 
times  during  the  night.  His  urine  was  also  beginning  to  assume  a  normal  color. 
The  patient  has  reported  to  me  since  then  and  his  urine  has  become  practically 
normal,  with  the  excejDtion  of  a  few  pus  cells  and  a  slightly  diminished  amount 
of  urea. 

The  favorable  outcome  of  these  cases,  without  surgical  interference,  does 
not  in  any  way  alter  my  opinion,  as  expressed  above,  that  renal  tuberculosis 
calls  for  timely  nephrectomy  in  the  best  interests  of  the  patient,  as  soon  as  a 
positive  diagnosis  has  been  made  and  the  functional  sufficiency  of  the  opposite 
kidney  has  been  established.  The  following  conclusions  will,  therefore,  show 
that  I  consider  tuberculosis  of  the  kidney  a  disease  to  be  treated  surgically  in 
the  majority  of  cases. 

Conclusions. —  (1)  I  believe  that  there  are  many  cases  of  polyuria  of  tu- 
berculous origin  not  diagnosticated  as  such. 

(2)  I  believe  that  there  are  many  cases  of  tuberculosis  of  both  kidneys  in 
which  the  process  is  cured  under  improved  general  conditions  of  treatment  and 
hygiene,  and  consequently  increased  bodily  resistance. 

(3)  .1  believe  that  there  are  patients  with  double  tuberculosis  of  the  kid- 
neys, one  organ  more  involved  than  the  other,  in  fairly  good  health  and  running 
a  slow  course,  who,  if  allowed  to  go  on  conservatively,  under  supportive  treat- 
ment, would  survive  the  disease,  through  the  healthier  kidney  performing  the 
work  for  both,  while  the  one  more  affected  would  continue  to  degenerate  until 
entirely  destroyed. 

(4)  I  believe  that,  in  any  suspected  case,  we  should  immediately  make  ani- 
mal inoculations  and  examine  specimens  of  urine  frequently. 

(5)  I  believe  that  most  cases  of  tuberculous  kidney  are  not  operated  on 
early  enough. 

(6)  I  think  that  better  cooperation  should  exist  between  the  patient  and  his 
physician,  on  the  one  hand,  and  the  surgeon  on  the  other. 

I  ma.j  here  add  that,  since  writing  this  chapter,  I  have  had  other  cases  in 
which  reno-vesical  tuberculosis  has  been  found,   that  have  been  successfully 


STATISTICS   OF  NEPHKECTOMY  IN  RENAL  TUBERCULOSIS    559 

treated  l)_y  the  treatment  above  outlined.  One  ease,  a  man  wIkj  eame  to  me  two 
years  ago  with  renal  tuberculosis  on  one  side  and  a  healthy  kidney  on  the  other, 
was  sent  to  the  hospital  for  neplirectomy.  Pie  delayed  entering  for  three  weeks. 
Then  he  was  again  examined  when  about  to  be  operated  upon  while  under  ether 
and  found  to  have  an  acute  parenchymatous  nephritis  of  the  former  healthy 
kidney.  He  was  accordingly  returned  to  bed  and  not  operated.  Since  then  I 
have  kept  him  under  observation  and  for  the  last  year  he  has  been  symptom at- 
ically  well  and  heavier  than  ever  before. 

Statistics  of  nephrectomy  in  renal  tuberculosis,  by  Albarran,  of  some  of 
the  prominent  operators  up  to  1905  shows: 

Albarran — 64  cases,  2  deaths.  Israel — 41  cases,  4  deaths. 

Eovsing — 47  cases,  3  deaths.  Kronlein — 34  cases,  2  deaths. 

Kiimmel — 43  cases,  5  deaths.  Casper — 20  cases,  2  deaths. 

The  total  is  7  per  cent  mortality. 


CHAPTEK    XXX 

HYDRONEPHROSIS 

(Uronephrosis) 

Hydkonepheosis  or  uronephrosis  is  a  chronic  distention  of  the  pelvic  cav- 
ity by  an  aseptic  liquid  derived  from  normal  nrine,  with  progressive  sclerosis 
of  the  vi^alls  of  the  sac. 

It  is  clinically  not  a  common  disease  and  the  apparent  freqnency  is  not  so 
great  as  the  real  frequency,  for  there  are  many  latent  cases  discovered  only  at 
autopsy.  It  is  twice  as  frequent  in  females  as  in  males  and  usually  affects  the 
right  side. 

Etiology. — Obstruction  of  the  excretory  channels  of  the  urine  and,  more 
particularly,  incomplete  obstruction  of  the  ureter  constitute  the  etiology  of 
hydronephrosis.  Obstacles  in  the  lower  urinary  tract  due  to  congenital 
anomalies  of  the  urethra,  such  as  a  narrow  meatus,  valvules  or  strictures  may 
serve  to  dilate  the  kidney,  but  only  after  the  whole  urinary  tract  has  been  dis- 
tended to  a  variable  extent.  The  moderate  bilateral  distention  seen  sometimes 
in  old  neglected  cases  of  acquired  strictures  of  the  urethra  is  rarely  aseptic  and, 
even  if  it  is,  it  does  not  deserve  to  be  considered  as  a  disease  in  itself,  being 
only  the  last  stage  of  a  generalized  urinary  dilatation.  Complete  and  sudden 
obstruction  of  the  ureter  by  stone  or  experimental  ligation  is  not  a  cause  of  true 
hydronephrosis,  as  in  these  case^the  kidney  at  first  becomes  somewhat  dilated ; 
but  this  stage  is  short,  and  is  rapidly  followed  by  renal  atrophy  and  sclerosis. 

Incomplete  obstruction  of  the  ureter  is  then  the  true  cause  of  hydrone- 
phrosis, either  congenital  or  acquired.  The  group  to  which  a  given  case  belongs 
is  usually  evident,  and  yet  it  is  sometimes  difficult  to  decide  what  was  the 
primary  cause.  The  tendency  at  present  is  to  recognize  as  congenital  many 
cases  that  w^ere  formerly  classified  in  the  acquired  class. 

CoNGEi^iTAL  Hydronephrosis.— The  knowledge  of  a  few  embryologieal 
conditions  enables  us  to  understand  Vvdiy  and  how  it  develops.  The  ureter,  dur- 
ing intra-uterine  life,  is  not  the  smooth  canal  we  are  accustomed  to  see  in  the 
adult,  but  is  constricted  in  some  places  and  dilated  in  others,  besides  showing 
in  its  lumen  numerous  valvules  formed  either  by  the  mucosa  alone  or  by  both 
the  mucous  and  muscular  layers.  These  formations  are  met  with  most  fre- 
quently at  the  uretero-pelvic  junction  and  next  at  the  lower  end  of  the  ureter. 
These  normal  valvules  disappear  later  under  the  influence  of  a  normal  gTOwth 
560 


ETIOLOGY 


561 


and  of  the  pressure  of  urine.  In  most  cases,  however,  they  have  not  completely 
disappeared  at  the  time  of  birth  and  consequently  the  ureter  in  the  newborn 
still  shows  a  number  of  irregularities,  both  on  its  outer  and  inner  aspects,  that 
must  be  considered  congenital  defects  and  later  may  cause  a  partial  obstruction 
of  the  ureter. 

If  the  obstruction  is  very  marked,  hydronephrosis  develops  during  fetal  life 
and  exists  at  the  time  of  birth,  sometimes  of  a  very  large  size ;  but  of  tener  the 
obstruction  is  but  slight  and  then  the  retention  is  more  progressive,  requiring 
years  of  slow  advance  to  develop  into  a  clinically  appreciable  tumor.  This  ex- 
plains why  hydronephrosis  appears  especially  as  a  disease  of  the  third  decade 
of  life.  Besides  the  increase  in  size  of  the  renal  pelvis  (the  sac),  hydro- 
nephrosis is  attended  by  the  development  of  certain  secondary  lesions,  such  as 
valvules  at  the  pelvic  origin  of  the  ureter,  kinks,  bends  and  adhesions  of  the 
upper  ureteral  segment.  All  of  these  complete  and  tighten  the  obstruction  and 
to  the  superficial  observer  seem  to  be  the  real  cause  of  the  .etention,  as  they  are 
much  more  apparent  to  naked-eye  ex- 
amination, and  much  easier  to  detect, 
than  the  often  small  and  indistinct 
congenital  defect  which  has  been  the 
real  cause  of  the  trouble.  For  this 
reason,  the  importance  of  congenital 
causes  has  not  been  properly  estimated, 
until  of  late  when  a  careful  study  of 
the  subject  has  shown  the  true  cause. 
Valvules  are  the  most  frequent  con- 
genital defects,  but  congenital,  ureteral 
strictures  also  occur  and  exert  the  same 
causal  influence. 

An  anomaly  of  position  also  predis- 
poses to  hydronephrosis.  Fig.  318 
shows  one  of  my  cases  which  was  lo- 
cated at  the  sacro-iliac  synchondrosis. 
An  effort  to  replace  it  failed  and  it  was 
removed.  The  body  of  the  kidney  was 
seven  inches  and  very  thin.  The  pelvis 
was  of  large  size. 

Besides  the  lesions  of  the  ureteral  wall  itself,  some  outside  anonuilies  may 
also  reduce  the  caliber  of  the  duct  and  cause  uronephrosis.  Such  compression 
may  be  due  to  an  abnoruuil  blood  vessel,  generally  an  artery,  very  exceptionally 
a  vein.  It  was  found  in  three  out  of  four  cases  (seventy-five  per  cent)  that 
the  inferior  branch  of  a  renal  artery,  given  off  prematurely,  passed  in  front 
of  the  uretero-pelvic  junction,  whereas  in  the  remaining  case  it  passed  pos- 


FiG.  318. —  Hydronephrosis  in  a  Kidney  7 
Inches  Long,  Situated  at  the  Sacro-iliac 
Synchondrosis.     (Author's  case.) 


562  HYDROXEPIIHOSTS 

teriorly.  Some  writers  eontciid  thai  an  artci-y  ])as.sino-  anteriorly  cannot  cause 
hydronephrosis,  and  it  is  certain  that  in  most  cases  this  is  true,  but  when 
the  dilatation  begins  exactly  at  the  point  where  the  artery  crosses  the  duct,  it 
may  have  a  causative  action. 

The  ureter  was  also  found  in  one  ease  to  be  compressed  by  a  band  represent- 
ing the  renu^ins  of  the  duct  of  Miiller,  and  in  another  case  Ijy  a  liand  repre- 
senting traces  of  the  Wolffian  duct. 

A  faulty  position  of  the  ureter  may  also  result  in  a  narroAving  of  its  lumen. 
Kinks  have  often  been  accused,  but  it  seems  that  in  many  of  the  cases  the  kink- 
ing w'as  secondary''  to  the  hydronephrosis  and  not  its  cause.  The  same  may  be 
said  of  a  faulty  insertion  of  the  ureter,  that  is,  either  too  high  or  too  obliquely 
into  the  pelvis. 

Torsion  of  the  ureter  is  always  mentioned  among  the  causes  of  congenital 
hydronephrosis,  and  yet,  real  torsion  is  exceedingly  uncommon,  as  there  are 
only  four  authentic  cases  of  such  a  condition  on  record. 

In  exstrophy  of  the  hladder,  the  fundus  of  the  viscus  forms  an  inverted 
pouch  in  which  the  intestines  lie,  and  the  loops  of  gut  press  on  the  ureter.  Some- 
times the  ending  of  the  ureter  in  the  bladder  is  not  normal,  either  because  the 
ureter,  after  having  gone  too  far  down  in  the  true  pelvis,  must  take  an  ascend- 
ing direction  to  reach  the  trigone,  or  because  the  intraparietal  course  is  too  long 
and  too  oblique. 

_  ISText  to  the  anomalies  in  the  position  and  caliber  of  the  ureter,  the  anomalies 
in  number  of  the  ducts  are  generally  mentioned  as  possible  causes  of  this  trouble. 

This  is  not  a  probable  cause,  however,  as  the  absence  of  one  ureter  cannot  be 
a  cause  of  hydronephrosis,  for  the  simple  reason  that,  if  the  ureter  does  not 
develop,  the  pelvis  cannot  exist.  IsTeither  can  supernumerary  ureters  cause  a 
retention  unless  they  are  strictured,  in  which  case  the  stricture  and  not  the 
numbers  of  ureters  is  the  cause.  The  same  applies  to  abnormal  endings,  for 
here  also  a  strictured  condition  of  the  end  must  exist  to  cause  retention  in  the 
kidney  on  that  side.  When  a  supernumerary  and  strictured  ureter  causes  a 
hydronephrosis,  it  almost  invariably  corresponds  to  the  upper  half  of  the  kidney. 

Congenital  hydronephrosis  is  often  associated  with  abnormalities  of  the 
kidney.  It  has  been  seen  in  single  kidneys  and  it  is  not  very  rare  in  horseshoe 
kidneys,  on  account  of  the  curve  the  ureter  has  to  describe  in  order  to  pass  in 
front  of  the  isthmus. 

Acquired  Hydeonepheosis. — We  find  here  the  same  mechanism  of  obstruc- 
tion: (1)  By  lesions  of  the  walls  of  the  ureter  itself ;  (2)  by  a  faulty  position: 
(3)  by  external  compression;  (4)  by  occlusion  by  a  foreign  body  lodged  within 
the  lumen. 

(1)  Obstructive  lesions  of  the  wall  of  the  ureter  are  not  very  common.  They 
sometimes  result  from  tuberculous  ureteritis.  Ordinary  ureteritis  leads  gener- 
ally to  pyonephrosis.     Acquired  strictures  of  the  ureter  are  also  rare. 


PATHOLOGY 


563 


(2)  Fdiilhj  pofiilinvt^  f)f  the  upper  part  of  the  ureter  are  produced  chiefly  by 
Irlilnri/  iiiohl/i/i/.  'I'lic  hiller  is  not  as  predominant  a  canse  of  hydronephrosis  as 
\\;is  fofiiK'vly  assuuH'd.  It  seems  fairly  well  cstaljlislicd  that  many  of  the  cases 
formerly  attributed  to  it  are  really  congenital  hydronephroses  due  to  some  of 
those  defects  ^ve  have  mentioned  ;  but  nevertheless,  movable  kidne_y  is  still  a 
cause  of  retention.  A  change  in  the  direction  of  the  kidney  and  ureter,  as  in 
scoliosis,  is  sometimes  sufficient. 

The  lower  extremity  of  the  ureter  may  be  occluded  in  procidentia  uteri,  or 
when  there  exists  an  intravesical  prolapse  of  that  end. 

(3)  External  compressions  are  the  most  important  causes  of  acquired  hy- 
dronephrosis and  cancer  of  the  uterns  and  of  the  prostate  occupy  the  foremost 
place.  Vesical  tumors,  uterine  fibroids,  tnberculous  glands  are  other  causes. 
Special  mention  mnst  be  made  of  pregnancy. 

(4)  Obstruction  hy  foreign  hodies  includes  stones  and  blood  clots.  The  lat- 
ter do  not  seem  resistant  enough  to  be  the  real  cause  of  retrodistention,  although, 
at  one  time,  the  theory  of  traumatic  hydronephrosis  was  based  np)on  them. 
Stones  cause  calculous  hydronephrosis  not  so 
much  by  the  obstruction  due  to  the  calculus  it- 
self, as  l)y  that  due 'to  the  lesions  of  the  ureteral 
wall  caused  by  the  pressure  of  the  stone. 


Fig.  319. — Hydronepheosis, 
First  Stage. 


Fig.  320. — Hydronephrosis, 

Second  Stage. 


Fig.  321. — Hydronephrosis, 
Third  Stage. 


Pathology. — When  an  obstruction  occurs,  the  urine  accumulates  in  the  renal 
pelvis  and  calicos  as  fast  as  it  is  secreted  (Fig.  319).  Gradually,  the  renal 
jjclvis  dilates  and  the  urine,  continuing  to  be  secreted,  compresses  the  renal 
substance,  disturbing  both  the  nutrition  and  the  secreting  capacity  of  the  paren- 
chyma and  rendering  the  stroma  anemic  (Fig.  320).  Gradually  under  the  in- 
fluence of  the  compression  and  degeneration  of  the  renal  vessels,  which  are 
jn-essed  upon  by  the  sac  pushing  forward  as  it  distends,  the  kidney  structures 
undergo  the  changes  of  interstitial  nephritis.  The  stronui  hypertrophies,  the 
parenehy-ina  degenerates  and  atrophies.  The  compression  and  distention  con- 
tinuing to  the  last,  the  kidney  is  converted  into  a  large  fibrous  cyst,  with  a  series 


564  HYDKOXEPHROSIS 

of  pouches  representing  the  calices,  separated  by  thin  septa,  representing  the 
remains  of  the  columns  of  Bertini  (Fig,  321).  These  pouches  may  communi- 
cate freely  with  the  general  cavity  or  be  shut  off  from  each  other  and  from  the 
pelvis  by  fibrous  partitions.  The  relative  degrees  of  the  involvement  of  the 
pelvic  calices  and  kidney  structures  varies  in  each  case,  the  extreme  type  al- 
luded to  above  being  comparatively  rare. 

The  'walls  of  the  hydronephrotic  cyst  may  be  thin,  translucent,  or  thick  and 
fibrous,  even  partially  calcified  in  old  cases. 

Adhesions  between  the  sac  and  the  surrounding  structures  add  sometimes 
considerably  to  the  thickness  of  the  walls.  The  size  varies  from  a  slight  dilata- 
tion of  the  normal  pelvis  to  an  enormous  bag  occupying  the  greater  portion  of 
the  abdomen,  and  sometimes  extending  to  the  true  pelvis.  This  depends  upon 
the  permanency  and  the  tightness  of  the  obstruction. 

The  contents  of  the  sac  are  at  first  simply  urine,  but  changes  promptly  fol- 
low. In  many  instances,  the  fluid  is  of  a  very  low  specific  gravity,  and  contains 
hardly  a  trace  of  urinary  constituents,  especially  when  the  renal  destruction  is 
considerably  advanced.  The  urinary  salts  are  gradually  absorbed  by  the  blood 
from  the  hydronephrotic  sac,  so  that  but  few  remain.  The  contents  may  be- 
come ammoniacal,  turbid,  sanguinolent.  If  infection  takes  place,  we  have  to 
deal  with  uropyonephrosis.  Sometimes  the  fluid  is  thickened  to  a  colloid  mass 
and  cholesterin  crystals  have  been  occasionally  met  with.  Smaller  or  larger 
amounts  of  albumin,  hyaline  casts  and  epithelia  have  also  been  found  in  the  sac 
contents. 

The  opposite  kidney  usually  presents  a  low-grade  nephritis,  but  much  less 
marked  than  in  case  of  pyonephrosis. 

Symptoms. — Many  cases  remain  latent.  As  a  rule,  the  subjective  symptoms 
are  reduced  to  a  minimum,  and  nothing  calls  attention  to  the  condition  until  a 
bulging  is  noticed  in  the  ileo-costal  region  on  one  side,  when  palpation  will  show 
a  tumor  varying  in  size  within  extremely  wide- limits.  This  tumor  is  usually 
first  felt  in  the  loin,  but  is  sometimes  distinctly  abdominal  from  the  beginning. 
In  the  majority  of  the  cases,  the  tumor  is  not  tender  and  appears  as  a  rounded 
or  lobulated  swelling  of  an  elastic  nature,  which  can  usually  be  ballotted  when 
not  too  large  and  heavy  or  too  flaccid.  Fluctuation  may  be  present  when  the 
walls  of  the  sac  are  not  too  much  thickened  or  when  the  tumor  is  not  very  tense. 
Respiratory  mobility  of  the  tumor,  always  more  marked  on  the  right  side,  may 
be  elicited  if  the  tumor  is  not  too  large. 

Cystoscopy  will  show  that  one  of  the  ureters  is  blocked  and  does  not  allow 
the  passage  of  urine  (complete  obstruction),  or  that  the  jets  are  weak  and  de- 
layed and  do  not  recur  in  the  same  rhythmic  succession  as  on  the  liealthy  side     | 
(incomplete  obstruction). 

Ureteral  catheterizaiion  will  show  the  presence  and  the  situation  of  the  ob- 
stacle, and  in  incom23lete  obstruction  the  catheter  may  be  able  to  pass  the  nar-    || 


SYMPTOMS  565 

row  point  and  obtain  a  varying  amount  oi  urine  from  the  renal  pelvis.  A  com- 
parison of  the  analytic  features  of  the  two  urines,  including  the  amount  of 
chlorids,  the  freezing  point  and  the  amount  of  urea  in  the  urine  on  each  side, 
will  show  the  difference  between  the  urine  of  the  healthy  kidney  and  the  hydro- 
nephrotic  fluid,  and  give  an  idea  as  to  the  secretory  value  of  the  distended 
kidney. 

The  tumor  may  give  rise,  like  any  other  abdominal  tumor,  to  certain  pres- 
sure symptoms.  These  are  chiefly  the  result  of  the  compression  of  the  lungs  and 
heart  caused  by  the  tumor  pushing  ujDward  against  the  diaphragm,  and  of  the 
c-i  impression  of  the  colon  due  to  the  forward  and  dowmward  extension  of  the  en- 
largement. Digestive  disturbances,  especially  obstinate  constipation,  are  com- 
mon symptoms  of  hydronephrosis  when  the  sacs  are  of  considerable  size. 

Symptoms  referable  to  the  cause  of  the  obstruction,  that  is,  renal  calculus, 
uterine  cancer  and  other  conditions,  may  form  the  salient  feature  of  the  clinical 
picture,  the  hydronephrosis  being  altogether  secondary. 

In  some  cases,  particular  symptoms  become  so  prominent  as  to  justify  the 
description  of  special  types  of  the  disease,  such  as  the  hematuric  type,  the  pain- 
ful type  and  the  intermittent  type. 

Hematuria  is  not  a  regular  symptom ;  in  fact,  it  is  very  rare,  but  has  been 
observed  by  several  surgeons,  and  is  sometimes  very  profuse.  The  contents  of 
the  renal  pelvis  may  be  sanguinolent  or  decidedly  bloody.  The  urine  may  be 
lightly  or  deeply  tinged  with  red.  All  this  depends  upon  the  congestion  fol- 
lowing distention. 

Pain  is  not  a  prominent  symptom  in  ordinary  cases  of  hydronephrosis,  but 
severe  attacks  of  abdominal  pain  and  renal  colic  are  the  rule  in  the  tyj)e  called 
intermittent.  They  sometimes  occur  when  there  are  large  and  tense  retentions 
and  may  even  be  seen  with  small  sacs.  The  pain  is  chiefly  due  to  the  distention 
of  the  pelvis.  It  can  be  produced  artificially  by  the  injecticm  of  cold  or  hot 
water  into  the  pelvis  through  a  ureteral  catheter.  When  a  certain  amount  is 
reached,  the  pain  becomes  very  severe,  much  like  that  of  renal  colic,  and,  if  the 
distention  is  not  promptly  relieved,  becomes  unbearable.  The  mechanism  of 
];ain  in  hydronephrosis  is  thus  made  obvious. 

Jnlermittence,  in  regard  to  the  pain  as  well  as  the  emptying  of  the  sac,  is 
a  striking  feature  in  many  cases  of  renal  retention,  and  a  special  type  know^n  as 
nilc}iiiillent  hydronephrosis  has  been  based  upon  the  connection  which  at  first 
sight  seems  to  exist  between  the  evacuation  of  the  sac  and  the  arrest  of  the  pain. 

Clinically,  intermittent  hydronephrosis  is  characterized  by  periodical  at- 
tacks of  pain,  during  which  the  kidney  becomes  enlarged  and  the  amount  of 
urine  voided  falls  off.  Later,  the  pain  subsides  and  the  kidney  decreases  in 
size,  while  the  amount  of  urine  voided  increases  to,  and  sometimes  considerably 
above,  normal. 

The  mechanical  cause  of  the  distention  and  pain  is  the  alternate  tightening 


566  HYDRONEPHROSIS 

and  releasing  of  the  ureteral  obstruction,  generally  cansecl  by  a  kink  of  the 
upper  part  of  the  ureter,  in  consequence  of  a  movable  kidney.  When  the  kidney 
falls,  the  ureter  kinks  and  urine  is  retained,  hence  j)ain  from  distention,  swelling 
and  oliguria  ;  but  when  the  kidney  returns  to  its  place,  the  urine  flows  freely, 
hence  polyuria  and  reduction  in  the  size  of  the  hydronephrotic  organ  (page  405). 

Unfortunately  for  the  value  of  the  theory,  the  succession  of  phenomena  is 
not  always  as  regular  as  it  should  be,  as  the  amount  of  urine  voided  at  the  end 
of  the  attack  is  in  excess  of  the  normal  amount  and  often  out  of  proportion  with 
the  size  of  the  organ.  Sometimes  there  is  more  than  a  gallon  after  the  attack 
in  a  case  Avitli  a  very  small  tumor ;  whereas  in  the  same  case  catheterization 
during  the  attack  did  not  show  more  than  one  ounce  in  the  pelvis.  Accordingly, 
there  seems  to  be  no  real  relationship  between  the  amount  of  urine  retained  in 
the  kidney  during  the  period  of  oliguria  and  the  subsequent  polyuria. 

A  conclusion  much  more  in  conformity  with  truth  would  be  reached  in  many 
cases  if  the  s^velling  of  the  kidney  were  attributed  to  renal  congestion  instead 
of  urinary  retention,  and  the  polyuria  interpreted  as  the  simple  result  of  the 
preceding  congestion. 

While  the  feature  of  intermittence  is  especially  pronounced  in  retention 
due  to  movable  kidney,  it  is  common  to  all  renal  retentions  and  is  shown  by 
each  at  some  period  of  its  development,  generally  during  the  early  stages. 

Complications. — Rupture  of  a  hydronephrotic  sac  is  rare.  It  may  be  intra- 
or  retro-peritoneal.  Complete  and  lasting  anuria  is  also  rare,  but  oliguria  and 
intermittent  anuria  are  common.     In  bilateral  cases,  m'emia  may  supervene. 

Infection  is  a  much  more  frequent  contingency.  It  leads  first  to  uropyo- 
nephrosis,  and  ultimately  to  pyonephrosis. 

Course. — The  course  of  hydronephrosis  is  usually  chronic  and  covers  years. 
The  tumor  acquires  a  large  size,  the  kidney  tissue  gradually  undergoing  com- 
plete destruction.  Less  frequently,  the  course  is  acute,  with  a  number  of  pain- 
ful attacks  which  recur  at  irregular  intervals.  A  chronic  hydronephrosis  may 
occasionally  change  to  the  acute  form  or  develop  acute  symptoms  temporarily. 

Diagnosis. — The  actual  diagnosis  is  based  on  the  presence  of  a  tumor  in  the 
flank  and  the  immediate  discharge  of  a  large  amount  of  clear  aseptic  fluid  on 
introducing  a  catheter  into  the  renal  pelvis,  or,  if  the  ureter  cannot  be  catheter- 
ized,  by  an  exploratory  incision  and  puncture  of  the  sac. 

The  differentiation  of  hydronephrosis  from  conditions  simulating  it  is  not 
always  a  simjDle  matter. 

Suppurative  conditions  in  the  kidney  itself  or  in  the  pelvis  are  frequently 
mistaken  for  hydronephrosis,  but  in  all  such  cases  in  which  infection  is  present, 
the  course  of  the  disease  is  more  rapid  and  acute  in  character  and  there  is  pus 
in  the  kidney  urine  from  that  side. 

In  cases  of  a  perinephritic  suppurative  condition,  there  are  always  symp- 
toms of  sepsis  and  a  lumbar  incision  is  immediately  indicated. 


TREATMENT  557 

Cysfs  of  the  I'ldncy,  liver,  spler7i,  mesenlery  and  other  abdominal  organs 
have  been  mistaken  for  hydronephrosis,  but  they  do  not  give  rise  to  the  urinary 
change.  Hydatid  or  other  cysts  of  the  kidney  may  be  suspected  when  urinary 
obstruction  can  be  excluded  and  v^^hen  a  fluid  circumscribed  tumor  exists.  Hy- 
datids of  the  liver  may  develop  in  any  part  of  the  organ  and  may  resemble 
liydronephrosis  when  they  appear  on  the  postero-inferior  aspect.  Generally, 
hy<hiti(l  cysts  of  any  intraperitoneal  organ  can  be  traced  by  palpation  or  per- 
cussion to  the  organ  with  which  they  are  continuous.  There  are  not  the  same 
urinary  changes  and  no  obstruction  to  the  ureter. 

Ovarian  Cysts. — These  grow  upward  instead  of  downward  as  in  hydro- 
nephrosis. Bimanual  examination  by  the  vagina  and  also  in  the  loin  will  gen- 
erally show  us  the  difference.  Hydronephrosis  developing  from  a  kidney  dis- 
]ilaccd  into  the  pelvic  cavity  has  led  in  a  number  of  instances  to  the  removal  of 
the  organ  (nephrectomy),  mistaken  for  an  ovarian  cyst. 

A  localized  accumulation  of  fluid  in  tuberculous  peritonitis  can  be  mistaken 
for  hydronephrosis,  as  it  may  form  a  tumor  in  this  region. 

The  completeness  or  incompleteness  of  the  obstruction  is  determined  by 
cystoscopy  and  ureteral  catheterization.  The  site  may  be  determined  by  the 
physical  examination  of  the  abdomen  and  by  the  examination  of  the  urinary 
tract  for  ureteral  obstruction  or  tumor  in  the  bladder ;  while  a  history  of  renal 
colics  would  point  to  a  calculus  in  the  ureter  on  that  side. 

The  state  of  tJie  opposite  kidney  is  determined  by  various  methods  of  diag- 
nosis described  in  the  chapter  on  Renal  Examination. 

Prognosis.^ — The  prognosis  depends  upon:  (a)  The  cause  of  the  obstruction, 
(b)  the  presence  of  compensatory  hypertrophy,  (c)  the  unilaterality  of  the 
liydronephrosis,  (d)  the  liability  to  infection  and  (e)  the  possibility  of  surgical 
relief.  As  a  rule,  patients  can  go  on  for  years  with  a  hydronephrosis  of  mod- 
erate size,  but  there  are  always  the  dangers  mentioned  to  be  borne  in  mind. 

Spontaneous  atrophy,  with  complete  obliteration  of  the  sac,  has  been  known 
to  occur,  but  a  return  to  the  normal  condition  is  impossible. 

Treatment. — An  acute  attack  of  pain  and  retention  occurring  in  the  course 
of  hydronephrosis  should  be  treated  palliatively  by  rest  in  bed  and  by  the  ad- 
ministration of  morphin  and  other  sedatives. 

The  radical  treatment  of  hydronephrosis  depends  upon:  (a)  The  cause  of 
the  obstruction,  {h)  the  site  of  the  obstruction,  (c)  the  condition  of  the  affected 
ki(hioy,  (c/)  the  condition  of  the  opposite  kidney.  The  princijdcs  which  must 
guide  us  in  the  choice  of  the  method  of  treatment  are:  (1)  We  must  preserve 
as  much  of  the  affected  kidney  as  possible,  and  give  the  remaining  parenchyma 
every  possible  chance  to  perform  its  function;  (2)  we  must,  if  feasible,  remove 
the  cause  of  the  obstnieticm  rallicr  tlian  its  effect;  (-])  we  must  not  remove  the 
diseased  kidney  unless  its  renniant  is  utterly  useless,  and  unless  the  opposite 
kidney  is  positively  known  to  be  healthy. 


568  HYDEONEPHROSIS 

The  surgical  measures  that  can  be  employed  in  hydronephrosis  are : 

.       .        r  (a)   Catheter  a  demeure. 

1.  Ureteral  catheterization  J  ;'^    ^^^    ,  .  ,   .         . 

-^  lib)    Washing  out  pelvis  and  ureter. 

2.  Puncture.  ^^   ^  ^  ^ 

3.  ISTephropexy, 

4.  Operation  to  restore  the  ureter. 

5.  Il^ephrolithotomy. 

6.  l^ephrotomy. 

7.  ^Nephrectomy. 

These  procedures  are  far  from  having  the  same  value.  We  shall  not  discuss 
here  nephrolithotomy,  which  comes  under  another  heading. 

Ueetekal  cathetekization  has  had  its  day,  in  the  treatment  of  hydro- 
nephrosis. The  cases  benefited  by  it  all  belonged  to  minor  retentions  due  to 
movable  kidneys. 

Puncture  should  never  be  employed,  as  it  is  attended  by  risks  of  infection 
and  an  escape  of  the  fluid  into  the  peritoneal  cavity. 

JN^EPHKOTOM Y  is  indicated :  ( 1 )  When,  the  opposite  kidney  being  destroyed, 
it  is  absolutely  essential  to  preserve  those  parts  of  the  hydronephrotic  organ 
which  have  been  spared  by  the  pressure  of  the  retained  fluid.  (2)  When 
hydronephrosis  exists  in  both  kidneys.  (3)  When  the  state  of  the  opposite  kid-- 
ney  is  unknown.  (4)  When  special  circumstances  exist  which  prevent  the  im- 
mediate removal  of  the  obstruction  to  the  urinary  flow  and  there  is  hope  of 
doing  so  at  some  future  time ;  also  when  a  renal  calculus  is  present  in  the  kid- 
ney or  ureter.  During  nephrotomy,  a  ureteral  catheter  should  always  be  passed 
from  above  downward  for  exploring  or  one  from  below  upward  for  drainage. 

The  fistula  remaining  after  nephrotomy  is  permanent,  unless  the  operation 
is  followed  by  a  secondary  nephrectomy  or  a  plastic  operation  on  the  ureter. 
The  edges  of  the  sac  should  be  stitched  to  the  wound,  including  the  lumbar  mus- 
cles as  in  nephrostomy.     Drainage  may  be  secured  by  means  of  a  tube. 

All  the  above-mentioned  methods  may  have  given  some  success,  but  they  are 
open  to  one  capital  objection,  namely:  That  they  do  not  remove  the  cause  of  the 
condition,  thus  classing  them  as  mere  makeshifts  and  not  advisable  procedures. 

The  same  cannot  be  said  of  the  three  which  are  left :  IsTephrectomy,  nephro- 
pexy, plastic  operations  and  anastomoses  on  the  ureter. 

ISTepheectomy  removes  the  pathological  renal  condition,  but  also  the  remain- 
ing functionating  tissue  of  the  diseased  organ.  It  should  therefore  be  the  last 
resort  and  should  not  be  even  considered  unless  the  surgeon  knows  that  the 
other  kidney  is  sound.  Primary  nephrectomy  must  be  reserved  for  those  long- 
standing cases  in  which  the  tumor  has  reached  a  large  size  and  appears  cystlike, 
with  thin  walls  and  ho  surviving  renal  tissue.  Secondary  nephrectomy  is  indi- 
cated in  the  presence  of  a  permanent  fistula  after  nephrotomy,  when  the  opened 


TEEATMENT  559 

diseased  kidney  is  useless  and  the  other  organ  sufficient  to  carry  on  the  work 
of  both. 

Nephropexy  and  operations  for  restoring  the  ureters  are  then  the  operations 
of  choice  in  the  treatment  of  hydronephrosis,  and  are  in  conformity  with  the 
modern  trend  of  renal  surgery. 

ISTephkopexy  should  be  the  operation  of  choice  in  cases  of  hydronephrosis 
caused  by  abnormal  mobility  on  the  part  of  the  kidney. 

It  is  important  in  all  cases  to  be  sure  that  the  ureteral  kink  is  not  fixed  by 
adhesions  and  does  not  remain  in  spite  of  nephropexy;  also  that  a  ureteral 
catheter  be  introduced  from  below  before  operating.  If  no  kink  is  felt  at  the 
time  of  operation,  nephropexy  is  performed ;  but  if  a  kink  is  felt,  or  the  ureter 
is  not  inserted  into  the  proper  part  of  the  renal  pelvis,  the  condition  of  the 
ureter  must  be  corrected  before  anchoring  the  kidney  in  proper  position. 

Operations  for  restoring  drainage  through  the  ureter  (pelvic  ure- 
teral operations)  are  in  all  respects  the  best  when  an  obstruction  is  present,  as  it 
is  evident  that  the  preservation  of  some  functionating  renal  tissue,  even  if  but 
little,  is  worth  some  extra  effort  on  the  surgeon's  part. 

We  do  not  intend  to  speak  here  of  the  operations  on  the  continuity  of  the 
ureter — ureterotomy  for  stone,  ureteroplasty  for  stricture,  etc. — but  will  con- 
sider the  treatment  of  the  most  common  cause,  that  is,  obstructive  lesions  in 
the  upper  part  of  the  ureter,  for  which  conditions  special  interventions  have  been 
devised.     These  are: 

(1)  The  division  of  the  spur  between  pelvis  and  ureter  (kentrotomy)  in 
case  of  abnormally  high  insertion  of  the  latter. 

(2)  Ureteroplasty  or  correction  of  a  stricture  of  the  ureter  based  on  the 
same  principle  as  pyloroplasty; 

(3)  Uretero-pyeloneostomy  or  transplantation  of  the  ureter  itself,  or  of  the 
ureter  with  an  adjacent  ring  of  pelvic  tissue  to  the  lowermost  point  of  the  sac. 

(4)  Lateral  anastomosis  of  the  ureter,  or  creation  of  a  communication  be- 
tween the  sac  and  the  ureter  below  its  obstructed  part.  This  is  recommended 
particularly  when  the  first  part  of  the  ureter  is  markedly  altered. 

(5)  Resection  of  the  Pelvis. — The  restoration  of  normal  excretion  of  urine 
may  also  be  brought  about  by  the  resection  of  the  lower  part  of  the  sac,  and 
anchoring  the  kidney  in  a  suitable  position,  tilting  its  upper  pole  toward  the 
median  line,  if  necessary.  This  seems  to  be  the  best  intervention  when  the 
ureter,  after  it  has  been  freed  from  its  adhesions,  shows  a  normal  lumen,  which 
is  very  often  the  case. 

(6)  Pyeloplication  or  capitonnage  of  the  exuberant  pelvis  is  a  good  com- 
plementary measure,  but  insufficient  when  employed  alone. 

(7)  In  a  few  of  the  rare  cases  of  hydronephrosis  developed  in  an  ectopic 
kidney  in  a  low  position,  direct  anastomosis  between  the  bladder  and  the  kidney 
has  been  successfullv  resorted  to. 


CHAPTER    XXXI 
OPERATIVE   SURGERY  OF  THE   KIDNEY 


External  exploratory. 
Internal  exploratory. 
Pyelotomy. 
XeplirojDexy. 
iN^ephrotomy, 


Operations 


Xephrostomy. 
]S[eplirectomy. 
Secondary  nephrectomy. 
Subcapsular  nephrectomy. 
Partial  nephrectomy. 


The  Routes 

Extraperitoneal. 

Intraperitoneal 

The  Incisions 

Vertical. 

Oblique. 

Transverse. 

Curved. 

Positions 

Lying  face  down  with  an  air  pillow  under  abdomen. 

Lying  on  back  with  sand  bag  or  block  under  upper  lumbar  region. 

Lying  on  healthy  side  with  block,  sand  bag,  or  other  sujiport  under  loin. 

Comhination  of  Routes,  Incisions  and  Positions 

Patient  on  abdomen.  Incision  vertical  or  curved  along  the 
outer  border  of  the  erector  spin^c  muscle,  only  recom- 
mended for  bilateral  nephropexy. 

Patient  on  back.  Incision  transverse  from  erector  spina'  to 
rectus  abdominis  muscle  (Pean's  operation).  Frequently 
used. 

Patient  on  the  healthy  side.  Incision  vertical,  curved, 
ol)lique  or  transverse.     The  curved  incision  is  the  best. 

Intraperitoneal.- — Patient  on  back.     Vertical  incision  along  the  outer  border 
of  the  rectus  abdominis  muscle.     Xot  recommended. 
570 


Extraperitoneal 


OPERATIVE  SURGERY  OF  THE  KIDNEY 


571 


The  extraperitoneal  operation  performed  throngh  a  curved  incision  in  the 
loin  with  the  patient  lying  on  the  healtliy  side  affords  the  best  means  of  operat- 
ing on  ninety  per  cent  of  the  cases  requiring  operation.     It  is  the  one  that  will 


Fig.  322. — Instruments  Used  in  Operations  on  the  Kidney. 


3, 
4, 
5, 
6, 
7, 
8, 
9, 
10, 


Scalpel  and  probe-pointed  bistoury.  11, 

Straight  pedicle  clamp.  12, 

Thumb  forceps.  IS, 

Straight  scissors.  l.'t. 

Mouse-tooth  forceps.  15, 

Curved  scissors.  16, 

Grooved  director.  17, 

Sponge-holding  forceps.  18, 

Curved  pedicle  clamp.  19, 

Artery  clamp.  20, 


Angular  pedicle  clamp. 

Guiteras  kidney  retractor. 

Intestinal  cylindrical  curved  needles. 

Needle  holder. 

Guiteras  abdominal  retractor. 

Hagedorn  needles. 

Straight  needles. 

Fenestrated  ureteral  catheter  and  guide. 

Probe-pointed  ureteral  catheter. 

Blunt-pointed  ureteral  catheter. 


principally  be  considered  in  this  chapter.     The  instruments  used  in  renal  sur- 
gery are  shown  in  Fig.  323. 

Throughout  the  text,  the  kidney  angles  and  triangles  will  be  occasionally 
spoken  of.  The  posterior  kidney  angle  is  at  the  junction  of  the  erector  spina2 
muscle  and  the  twelfth  rib.  The  posterior  kidney  triangle  is  formed  by  the  con- 
tinuation of  the  lines  making  the  triangle  until  tlie}^  meet  the  umbilical  line. 
In  Fig.  323,  the  inner  side  of  the  triangle  which  corresponds  to  the  outer  border 
of  the  erector  spina'  muscle  is  3^  inches  long  {A-B).  The  outer  side  of  the 
triangle  corresponds  to  the  lower  border  of  the  twelfth  rib  2^  inches,  and  a  line 
continuing  from  its  tip  to  the  umbilical  line  2  inches  more,  making  4-^  inches 
{A-C).  The  base  along  the  umbilical  line  would  be  about  3  or  more  inches 
(B-C).  The  uml)ilieal  ki<lney  line  extends  around  the  body  at  the  level  of  the 
upper  border  of  the  undiilicus  and  corresponds  to  the  lower  border  of  the  right 
kidney.     The  deep  markings  of  this  triangle  vary  according  to  the  size  of  the 


572 


OPERATIVE    SURGERY    OF    THE    KIDXEY 


erector  spinse  muscle,  the  slope  and  length  of  tlie  twelfth  rib  and  the  length  of 
the  ileo-costal  space.  The  surface  markings  vary  according  to  the  amounl  of 
fat  in  this  region. 

The  anterior  kidney  angle  in  front  is  at  the  junction  of  the  outer  border  of 
the  rectus  abdominal  muscle  and  the  free  border  of  the  ribs  which  correspond  to 
the  tip  of  the  ninth  costal  cartilage.  (See  Fig.  324. )  The  anterior  kidney  tri- 
angle is  formed  by  the  continuation  of  the  lines  going  to  form  the  kidney 


Fig.  323. — Posterior  Kidney  Angle. 


'\  \ 

iV  ^ 

^■^ 

\  \  ^ 

-v.*'/"~7— 

l\    \ 

"^-L_ 

i\^ 

Fig.  324. — Antehior  Kidney  Angle. 


angle  to  the  umbilical  line  (A-B-C).  The  inner  border  is  2.1-  inches  long 
along  the  outer  side  of  the  rectus  abdominis  muscle  (A-B)  and  the  outer  3-^ 
along  the  costal  margin  and  continued  to  the  umbilical  line  (A-C).  The  length 
of  the  base  (C-B)  corresponds  to  the  size  and  the  rounding  of  the  body.  These 
measurements  vary  greatly  in  different  individuals  and  are  the  result  of  an 
average  made  from  a  number  of  cadavers  while  teachino-  anatomv  in  1894:. 


INCISIONS 

Vertical  Incisions. — The  postekiok  vertical  ixcisiox  is  one  made  M'ith 
the  patient  lying  face  dovmward  with  a  pillow,  sand  bag  or  some  other  support 


INCISIONS 


573 


under  the  abdomen.  It  begins  at  the  apex  of  the  posterior  kidney  angle,  that  is, 
the  junction  of  the  twelfth  rib  and  the  erector  spinse  muscle,  and  extends  down 
along  the  outer  border  of  the  erector  spina?  muscle  (Fig.  325).  It  is  the  one 
usually  used  in  performing  nephropexy,  although  the  vertical  incision  can  be 
made  equally  well  with  the  patient  lying  on  the  side  opposite  the  kidney  to  be 
operated  upon.  The  posterior  incision  has  the  advantage,  however,  in  per- 
forming a  double  nephropexy,  as 
then  the  position  of  the  patient 
does  not  have  to  be  changed  during 
the  operation. 


Fig.  325. — Posterior  Vertical  Incision 
Seen-  on  the  Left  and  the  Short 
Curved  Incision  on  the  Right. 


Fig.  .326. — Anterior  Vertical  Incision  Seen  on  the 
Right  Side  and  the  "  Modified  "  Incision  on 
the  Left. 


AxTEKioE  Vektical  Ixcision  (Fig.  32G). — The  anterior  incision  is  made 
with  the  patient  lying  on  the  back  with  a  support  underneath  the  vertebra?.  It 
begins  at  the  anterior  kidney  angle,  that  is,  at  the  juncture  of  the  ninth  cos- 
tal cartilage  and  the  rectus  abdominis  muscle,  and  extends  downward  along 
the  outer  side  of  this  muscle  to  a  point  two  inches  below  the  umbilical  line. 
This  incision  is  used  principally  for  removing  the  kidney  through  the  peri- 
toneum in  cases  of  a  large  renal  tumor.  Sometimes  a  short  incision  is 
made  outward  from  the  main  incision,  at  right  angles  to  it,  when  more  space 
is  needed. 

Lumbar  Incision. — Tlio  lumbar  incision  with  the  patient  lying  on  one  side 
is  the  one  generally  used  in  this  country  and  may  be  either  transverse,  vertical, 
curved  or  oblique. 


574 


OPERATIVE    SURGERY    OF    THE    KIDXEY 


Transverse. — The  transverse   incision   is  usually   made   with   the   patien- 
lying  on  the  back  in  the  same  position  as  for  the  anterior  incision,  and  extends 

along  the  umbilical  line  from  the  erector  spins? 
to  the  rectus  abdominis  muscle  (Fig.  327).  It  is 
alsf)  made  ^vitll  the  patient  lying  on  one  side. 

Vertical. — The  vertical  incision  is  made  in 
the  same  way  when  the  patient  is  lying  on  the  side 
as  when  lying  on  the  abdomen.  It  is  rather  small 
for  extensive  operations  and  is  used  ])rineipally 
for  fixing  in  place  a  moval)le  kidney  and  for  ex- 
ploring the  organ.     (See  Fig.  325.) 

Curved. — The  curved  lumbar  incision  is  the 
most  conservative,  as  well  as  the  most  economical 
as  far  as  the  expendit\ire  of  tissue  is  concerned. 
Here  the  incision  begins  as  a  vertical  one  and  extends  down  nearly  to  the  crest  of 
the  ilium  (Fig.  32S),  where  it  begins  to  curve  toward  the  anterior  superior  spine 


Fig.  327. — Transverse  Incision. 
The  patient  lying  on  the  back 
or  side. 


Fig.  328. — Curved  Lumbar  Incision.     The  position  preferred  in  renal  surgery. 


of  the  ilium,  sometimes  passing  it  when  more  space  is  needed,  as  is  frequently 

the  case  when  a  nephrotomy  or  a  nephrectomy  in  pathological  kidneys  is  being 

performed.     Care  must  be  taken,  in 

making  this  incision,  not  to  go  too 

near  the   crest  of  the   ilium,   as   in 

such    a    ease    it  is  more  difficult  to 

close    it    satisfactorily     afterwards. 

This  incision  can  be  continued  for 

any  distance,  even  along  the  rectus 

abdominis  muscle  to  the  pubes. 

Oblique. — The  oblique  incision 
begins  at  the  erector  spinse  muscle,  t^     .„^     ^ 

*-'    _  ^  _  '  Fig.  cS29. — Oblique  Lumbar  Incision. 

one    inch    below    the  twelfth   rib,    and  The  patient  lying  on  one  side. 


INCISIONS 


575 


cxtoii<ls  in  a  (lircction  parallfl  to  this  rib  as  far  as  noocssary  to  complete  tlie 
()|i('i'a1  idii.  It  is  a  wvy  uoitd  iiK'isidii,  hut  does  not  leave  the  ahdominal  wall 
stronii',  as  does  the  eurved  one  (Fitx.  ''>i!t»). 

Posterior  Vertical  with  Curved  Lumbar  Incision. — The  incision  used  in 
descrihino'  the  following-  operations  will  he  the  posterior  vertical,  to  be  contin- 
ned  into  the  enrved  Inmhar  when  more  space  is  needed. 

The  I'osiTioN  of  the  patient  in  making'  this  himhar  incision  is  lying  upon  the 
healthy  side  with  the  arm  and  thigh  of  that  side  flexed,  as  is  shown  in  Fig.  328. 
Sometimes  the  thigh  of  the  healthy  side  is  extended  and  the  one  on  the  side 
of  the  ojicration  is  flexed  and  the  knee  rests  on  a  sand  bag.     The  first  of  the 


Fig.  330. — Operating  Table.  This  has  a  transverse  iron  plate  running  across  it  that  can  be  elevated 
to  any  distance  for  regulating  the  patient's  position.  The  pegs  in  the  ii'on  plate  prevent  the  body 
from  slipping. 

two  positions  is,  however,  preferred.  A  support  should  be  placed  on  the 
table  under  the  healthy  side  of  the  patient  of  such  a  size  and  shape  that  it 
Avill  separate  as  far  as  possible  the  space  between  the  border  of  the  ribs  and  the 
ilium  of  the  side  to  be  operated.  This  supp(^rt  should  not  be  so  high,  however, 
as  to  push  the  healthy  shoulder  or  hi})  of  the  patient  above  the  level  of  the 
table,  but  only  a  sufficient  distance  to  stretch  the  field  of  operation.  Once  in 
place,  sand  bags  should  be  placed  about  the  body  in  such  a  way  as  to  retain  it 
in  the  desired  position.  Very  often,  pulling  on  the  kidney  or  leaning  on  the 
body  tends  to  push  the  patient  out  of  position  unless  sand  bags  are  used.     The 


576 


OPERATIVE    SURGERY   OF    THE    KIDNEY 


support  under  the  liealtliy  loin,  which  T  have  spoken  of,  may  be  a  sand  bag, 
a  cushion,  one  or  two  bricks,  a  log,  a  small  back  rest,  or  some  support  which  is 
sufficiently  narrow  to  catch  in  the  ileo-costal  space.     A  wedge-shaped  support 


Fig.  331. — Body  Holder  for  Preventing  the  Patient  from  Rolling  when  Lying  on  the  Side. 
The  rods  extend  out  obliquely  in  front  and  behind  and  rest  on  the  table. 

sometimes  fits  admirably  in  this  space.  Many  of  the  tables  now  used  for  opera- 
tions have  a  slab  extending  across  them,  that  can  be  elevated  to  any  degree  de- 
sired, which  graduates  the  position  of  the  patient  better  than  any  other  method 
(Fig.  330). 


Fig.  332. — The  Body  Holder  on  the  Patient,  to  Prevent  Him  from  Rolling. 

Body  holders  are  also  constructed  to  hold  the  body  in  the  desired  position 
and  prevent  the  patient  from  rolling  during  the  operation  (Fig.  331).  The 
body  holder  is  made  of  a  wide  canvas  belt  to  which  two  iron  bars  are  attached 
by  clasps.  When  this  is  strapped  about  the  body  below  the  axillas,  the  bars 
extend  out  obliquely  to  the  surface  of  the  table  on  either  side  and  hold  it  firmly 
in  place  (Fig.  332). 


INCISIONS 


577 


In  describing  surgical  operations  on  the  kidney,  I  shall  first  show  them  as 
they  are  performed  by  the  lumbar  incision  with  the  patient  lying  on  the  healthy 
side,  as  operations  in  adults,  excepting  double  nephropexy,  can  be  performed 
by  this  route  better  than  by  any  other.  In  renal  tumors  in  children,  the  ab- 
dominal route  is  the  one  of  choice.  In  adults,  I  have  never  as  yet  had  to  resort 
to  it,  the  curved  lumbar  incision  always  having  answered  the  purpose. 

Technique  of  Operation. — I  think  that,  for  the  sake  of  clearness,  it  is 
advisable  for  me  to  describe  first  the  kidney  operation  according  to  my  routine 
method  and  then  to  take  up  those  preferred  by  other  surgeons. 


Fig.  3.33. — Incision  through  the  Skin  and  Superficial  Fascia,  Revealing  Petit's  Triangle.  (1) 
Latissimus  dorsi  behind.  (2)  External  oblique  in  front  and  the  iliac  crest  below.  Its  floor  is  the 
internal  oblique  (3). 

The  technique  of  operations  by  the  curved  incision  in  the  loin  is  as  follows : 
The  incision  is  begun  one  inch  above  the  apex  of  the  kidney  angle,  that  is,  just 
above  the  twelfth  rib,  and  extends  down  along  the  outer  border  of  the  erector 
spina^  muscle  to  within  one  and  a  half  inches  of  the  crest  of  the  ilium,  at  which 
])oint  it  should  be  curved  toward  its  anterior  superior  spine  (Fig.  328).  The 
skin  is  first  cut  through  and,  with  the  fatty  tissue,  is  dissected  back  on  either 
side  for  half  an  inch,  so  as  to  leave  sufiicicnt  space  of  exposed  external  fascia 
for  the  passing  of  sutures  in  closing  the  wound.  The  latissimus  dorsi  and  the 
external  oblique  are  then  seen  forming  Petit's  triangle  below  (Fig.  333).  The 
latissimus  dorsi  muscle  and  the  superficial  fascia  should  then  be  incised  along 
the  outer  border  of  the  erector  spinse  muscle  which  can  easily  be  outlined.  The 
serratus  posticus  inferior,  the  erector  spina',  the  oblique  muscles,  the  twelfth 
rib,  the  Uunbar  fascia  are  then  seen  (Fig.  334).  The  serratus  posticus  inferior, 
the  external  and  internal  oblique  and  the  deep  lumbar  fascia  are  then  cut  through 


578 


OPERATIVE    SURGERY   OF    THE    KIDXEY 


(Fig.  335)  and  some  of  the  lumbar  nerves  are  seen.     The  kidney  region  is  here 
clearly  disclosed.     The  deeper  part  of  the  incision  should  be  made  in  this  space 


Fig.  334. — IisrcisiON  through  LATissnrtJS  Dorsi  Muscle  (7),  showing  Bexeath  It:  (1)  The  trans- 
versalis  fascia;  (2)  the  external  oblique  muscle;  (3)  the  internal  oblique;  (4)  the  bifurcation  of  the 
transversalis  fascia;  (5)  the  erector  spinse  muscle;  (6)  the  serratus  posticus  inferior  and  (8)  the 
twelfth  rib. 


from  the  rib  downward  along  the  outer  side  of  the  quadratns  muscle,  and 
through  the  internal  lumbar  fascia.  On  cutting  through  this  fascia,  the  fatty 
capsule  is  seen  (Fig.  336).     The  incision  in  the  fascia  is  prolonged  and  the 


Fig.  33.5. — Muscles  (1,  3,  4,  Zand  8)  Cut  Through;  That  Is,  the  Latissimus  Dorsi,  the  Serratus 
Posticus  Inferior,  the  Transversalis,  and  the  Internal  and  Extern.\l  Obliques.  The 
twelfth  rib  (2)  is  seen  on  the  outer  side,  (6)  the  quadratus  lumborum  on  the  inner  side.  The  deep 
fascia  with  (5)  the  lumbar  nerves  (the  ileo  hypogastric  and  the  ileo  inguinal)  are  also  seen. 


INCISIONS 


579 


fatty  capsule  is  grasped  by  sponge  forceps  and  cut  through,  disclosing  beneath 
it  the  kidney  covered  by  its  capsula  propria.  The  organ  usually  moves  up  and 
doAvn  with  inspiration  and  expiration.  Preparations  are  now  made  for  per- 
forming renal  explorations  and  operations. 


Fig.  336. — Deep  Lumbar  Fascia  Cut  Through,  showing  the  Fatty  Capsule  of  the  Kidney. 

Treeing  and  Delivery  of  a  Kidney. — The  forefinger  or  the  fore  and 
middle  fingers  of  one  hand  are  now  inserted  between  the  fatty  capsule  and  the 
capsula  propria  on  the  posterior  part  of  the  kidney,  with  the  palmar  surface 


Fig.  337. — Freeing  the  Kidney.  The  fatty  capsule  is  caught  with  sponge  forceps,  the  kidney  is 
brought  into  the  wound  while  the  fatty  capsule  is  separated  from  it  by  the  forefingers  working  on 
either  side  of  the  kidney  at  the  same  time. 


next  to  the  orean,  while  the  forefinger  of  the  other  hand  is  introduced  between 
the  two  capsules  in  front.  The  fingers  then  move  to  and  fro  over  the  renal  sur- 
face in  opposite  directions,  pushing  the  fatty  capsule  away  from  the  organ  (Fig. 


580 


OPERATIVE    SURGERY    OF    THE    KIDNEY 


Fig.  338. — Delivery  of  the  Kidney.  This  is  often  quite  easy 
in  cases  of  movable  kidney  as  the  kidney  is  grasped  by  its 
fatty  capsule,  pulled  down  until  its  upper  pole  is  below  the 
ribs,  when  it  is  pulled  up  and  out  over  the  rib.    (After  Ashton.) 


33V).     Sometimes  tliis  is  easily  (lone,  while  again  difficnlties  are  encoimtered 
on  the  anterior  surface  and  at  the  n])per  and  lower  poles.     In  the  case  of  a 

kidney  that  is  movable 
hut  not  ]):itholo<iieally  dis- 
eased, the  freeing  (jf  the 
organ  is  quite  easy  and 
\-ery  often,  after  the  fatty 
capsnle  has  heen  incised, 
its  sides  can  be  grasped 
and  the  kidney  pulled 
down  until  its  up])er  pole 
is  Ijelow  the  twelfth  rib 
and  then  lifted  ont  of  the 
wound  as  a  sling  with  the 
kidney  within  it  (Fig. 
338).  At  other  times  the 
lower  leaflet  of  the  peri- 
renal fascia  can  be  grasped 
with  sponge-holding  forceps  and  i^nlled  down,  while  th'e  forefinger  of  one  hand 
is  placed  under  the  lower  pole 
of  the  kidney  and  it  is  hooked 
out  (Fig.  339).  The  lower 
pole  is  then  grasped  by  the 
fingers  of  the  right  hand  and 
steadied,  while  the  forefinger 
of  the  left  hand  is  passed  un- 
der the  upper  pole,  and  lifts 
it  out  of  its  cavity  and  over 
the  twelfth  rib  (Fig.  340). 

In  case  it  is  easier  to  de- 
liver the  upper  pole  first,  it  is 
steadied  by  the  fingers  of  the 
left  hand  while  the  forefinger 
of  the  right  hand  is  passed 
under  the  lower  pole  and 
hooks  it  out. 

In  the  case  of  a  patholog- 
ical kidney,  however,  there  are    Fig.  339. — Delivery  of  the  Kidney.     When  the  lower  pole 
n,  J.    TiY<      li."        •  is  hard  to  deliver,  the  forefinger  is  placed  beneath  it  and 

often  very  gi-eat  difficulties  m        hooks  it  out. 

freeing  the  organ  on  account 

of  the  dense  adhesions  and  the  lack  of  mobility  on  the  part  of  the  kidney.     In 

the  first  place,  the  adhesions  between  the  fatty  capsule  and  the  eapsula  propria 


INCISIONS 


581 


are  at  times  so  dense  that  tliey  cannot  be  separated,  in  wliicli  ease  the  kidney  has 
to  be  delivered  Avitliont  either  of  its  capsules,  or  else  an  extensive  dissection 
has  to  be  made  through  the 
combined  fatty  capsule  and  cap- 
snla  propria.  A  thick  mass  of 
fat  also  extends  up  and  down 
along  the  leaflets  of  the  perirenal 
fascia,  often  forming  dense  tis- 
sue above  and  below  the  organ. 
In  such  cases,  it  is  necessary  at 
times  to  cut  through  this  dense 
tissue ;  but  before  doing  so,  it  is 
important  to  free  the  kidney  as 
much  as  possible  and  it  is  often 
necessary  to  insert  the  entire 
hand  through   the   incision   and, 

f'iG.  340. — Delivery  of  the  Kidney.  When  the 
lower  has  been  delivered,  it  is  grasped  with  the 
fingers  of  one  hand  and  pulled  downward  while 
the  forefinger  of  the  other  hand  is  hooked  under 
the  upper  pole  and  draws  it  out. 


Fig.  341. —  Delivery  of  the  Kidney.  In  many  cases  it  is  difficult  to  draw  the  kidney  down  and  it 
is  necessary  to  insert  the  hand  into  the  wound  until  the  fingers  are  above  the  kidney  to  loosen  its 
pole  before  bringing  it  down.     It  is  then  delivered  in  the  way  already  explained. 


582  OPERATIVE    SURGERY   OF    THE    KIDNEY 

having  reached  the  fingers  above  tlie  kidney,  to  free  the  organ  gently  nntil  it 
can  be  brought  down  into  the  operative  field  (Fig.  341). 

Cutting  through  these  masses  of  tissue  often  gives  rise  to  considcraljle  hem- 
orrhage and  is  sometimes  a  very  alarming  procedure  to  the  practitioner  who  is 
doing  his  first  kidney  operation  for  stone,  tumor  or  tuberculosis,  as  in  these 
classes  of  cases,  especially  the  first,  the  sclerosis  is  most  uuirked.  He  must  not 
hurry,  however,  or  become  flustered,  but  iimsl  rciiicnibcr  to  shut  off  the  ves- 
sels by  clamps  and  ligatures  before  cutting  through  the  tissue  above  and  below 
the  kidney.  In  ligating  this  mass,  it  is  advisable  to  clamp  the  tissue  and  then 
to  pass  ligatures,  threaded  on  a  needle  by  the  aid  of  a  needle  holder  outside, 
above  or  below  the  clamps,  allowing  sufficient  space  for  cutting  thr(»ug]i  the 
tissue  between  the  ligatures  and  the  kidney.  In  this  way,  the  ligatures  have 
a  better  hold  on  the  tissue  and  bleeding  is  ccmtrollcd. 

In  cutting  through  and  tying  off  this  tissue  below  the  kidney,  the  operator 
must  be  careful  not  to  include  the  ureter  in  the  ligature.  It  is  therefore  advis- 
able, in  the  case  of  a  dense  mass  of  tissue  below  the  lower  pole  in  the  region 
of  the  ureter,  first  to  find  the  ureter  and  dissect  up  along  it  to  the  pelvis  of  the 
kidney  and  then  to  free  and  retract  it  while  the  kidney  is  being  liberated.  In 
fact,  it  is  always  advisable  in  any  operation  on  the  kidney  to  have  control  of 
the  ureter  at  an  early  period  of  the  work.  After  having  freed  the  ureter  up  to 
the  pelvis  of  the  kidney,  the  back  of  the  forefinger  is  placed  against  the  anterior 
surface  of  the  ureter  and  it  is  then  pushed  up  to  the  pedicle.  The  forefinger 
should  then  be  turned  and  hooked  behind  the  pedicle,  and  its  tip  brought  out 
above  it,  pointing  forward.  The  pedicle  will  then  be  under  complete  control, 
which  will  assist  in  freeing  the  anterior  adhesions  and  preventing  any  trau- 
matism of  the  vessel. 


EXPLORATIONS    AND    OPERATIONS 

External  Exploration  of  a  Pathological  Kidney. — A  cystic  kidney  can  be 
determined  by  the  irregular  cystic  protuberances  over  its  surface,  showing  cystic 
degeneration,  or,  in  case  of  a  large  serous  cyst,  by  a  large  sac.  A  tumor  can  be 
detected  by  the  enlargement  of  the  organ  and  the  increased  consistence  and 
nodular  feel  of  the  new  growth.  A  tuberculous  kidney  is  enlarged  and  reddened 
with  hard  and  bulging  areas,  in  places  in  an  acute  condition ;  whereas,  if  the 
kidney  is  quite  extensively  destroyed  by  a  suppurative  process,  the  color  is  lighter 
and  the  surface  is  more  irregular  and  soft  areas  may  be  felt  on  the  outside,  which 
are  abscesses  or  abscess  cavities.  If  there  is  much  pus  in  the  pelvis  or  in  cav- 
ities of  the  kidney,  it  may  have  a  mushy  feel.  Groups  of  tubercles  may  also  be 
seen  beneath  the  capsula  propria.  In  case  of  a  stone  in  the  kidney,  the  organ 
is  usually  very  much  indurated,  somewhat  enlarged  and  has  considerable  fat 
about  it ;  while  in  a  suppurative  case,  there  might  be  considerable  enlargement 


EXPLORATIONS  AND  OPEEATIONS 


583 


through  retention  of  pus  or  pns  and  nrinc,  making  it  difficult  to  detect  the 
calculi. 

Aspiration. — Jn  ease  there  is  a  retention  of  pus  or  urine  in  the  kidney 
which  enlarges  it  to  such  a  degree  that  it  cannot  be  easily  delivered,  an  aspirat- 
ing needle  can  be  inserted  and  sufficient  fluid  removed  to  allow  freer  manipu- 
lation of  the  organ,  and  a  sufficiently  satisfactory  palpation  can  be  made  to 
detect  the  presence  of  calculi. 

In  aspirating,  it  is  advisable  to  have  the  outflow  nozzle  of  the  aspirator  con- 
nected with  a  tube,  in  order  that  the  aspirated  fluid  may  be  pumped  into  a  recep- 
tacle held  outside  of  the  operative  field. 

Internal  Exploration  of  the  Kidney. — Pyelotomy  is  another  name  for  an 
incision  of  sufficient  size  to  admit  the  forefinger  in  the  renal  pelvis,  and  should 
be  made  on  its  posterior  surface  from  near  the  kidney  downward  in  the  direc- 
tion of  the  ureter.  The  operation  is  really  an  exploratory  one  and  is  indicated 
in  aseptic  cases  in  which  a  stone  in  the  renal  pelvis  is  suspected. 

Technique.  The  kidney  is  delivered  and  pushed  over  the  upper  border  of 
the  incision  in  such  a  way  as  to  put  the  pelvis  on  the  stretch.  It  is  then  steadied 
with  the  left  hand,  while  the  pelvis  is  incised  by  the  knife  in  the  right  hand. 
The    incision    is    made 

from   near    its   junction  — "  '  " 

with  the  kidney  longi- 
tudinally toward  the  ure- 
ter to  a  sufficient  extent 
to  allow  the  end  of  the 
forefinger  to  enter  (Fig. 
342).  The  finger,  hav- 
ing been  introduced  into 
the  pelvis,  explores  its 
cavity  and  the  tip  is  in- 
serted into  the  different 
calices,  by  which  means 
a  stone  can  be  easily  de- 
tected and  if  small  can 
be  withdrawn  without 
difficulty     with     curved 

forceps.       11   no    stone    is    Yio.  342. — Examination  of  the  Kidney.      The  kidnej'  after  deliv- 
present     the  incision  can  cry  is  examined  by  palpation  and  sometimes  the  pelvis  is  opened 

,         ,         ,    ,  -r        ,  longitudinally,  pyelotomy,  and  the  forefinger  introduced  palpates 

be  closed  by  a  Lembert       ^^.g  calices. 
suture.     This  is  a  sim- 
ple procedure  in  a  thin  individual  in  whom  plenty  of  space  is  present,  and 
is  attended  by  very  little  bleeding.     The  operator  must  be  very  careful  not  to 
cut  through  both  sides  of  the  pelvis  in  making  the  incision,   for  the  tissues 


584 


OPERATIVE    SURGERY   OF   THE   KIDNEY 


are  on  the  stretch  and  the  anterior  and  posterior  walls  are  often  flattened  on 
one  another. 

It  is  safer  to  have  an  assistant  steady  the  kidney  with  one  hand  and  then  for 
the  operator  and  the  assistant  to  pick  iq)  the  wall  of  the  pelvis  with  thumb  for- 
ceps and  cut  between  them. 

Further  internal  exploration  of  the  kidney  requires  a  vertical  incision 
through  its  convexity  which  will  allow  us  to  see  calculi  or  tubercular  nodules 
or  abscess  cavities.     This  operation  will  be  considered  later  under  nephrotomy. 

Nephropexy. — There  are  very  many  operations  for  fixing  a  movable  kidney, 
but  I  shall  describe  only  my  own  operation,  which  was  formulated  by  me  to 
cover  the  different  difficulties  that  are  met  in  anchoring  the  organ. 

Technique  of  ISTephropexy. — The  patient  should  be  placed  either  face 
down  with  a  pillow  under  the  abdomen,  or  else  on  the  healthy  side  with  a  sand 


Fig.  343. ^Operation  for  Movable  Kidney.  The  fixation  sutures  are  passed  through  the  abdom- 
inal wall  before  the  kidney  is  delivered  and  then  hang  on  either  side  of  the  patient  while  the  kidney 
is  being  operated  on. 


bag  or  some  other  support  under  the  loin.  The  latter  position  w'ill  be  consid- 
ered, as  it  is  much  easier  to  describe  first  all  the  operations  that  can  be  done 
in  this  position.  The  incision  is  the  vertical  one  already  shown,  to  be  curved  if 
necessary.  (See  Fig.  325.)  Before  delivering  the  kidney,  I  j^ass  the  fixation  su- 
tures through  the  abdominal  wall  excepting  the  skin,  two  fixation  sutures  through 
the  muscles  and  fascias  on  the  inner  side  of  the  incision  below  the  twelfth  rib  and 
one  through  the  outer  side  (Fig.  343).  The  first  suture  is  passed  through  the 
erector  spinse  muscle  and  other  muscles  and  fascia  just  below  the  twelfth  rib,  and 
the  second  or  lower  one  is  passed  through  the  same  tissues  about  one  inch  below 
the  upper  one.     The  third  fixation  suture  is  passed  through  the  abdominal  on 


EXPLORATIONS  AND  OPERATIONS 


585 


the  inner  side  of  the  incision  in  a  space  correspond  in  i;'  In  tliat  hctuccn  llie 
sutures  on  the  outer  side.  It  is  impossible  to  put  in  two  traction  sutures  on 
either  side  of  the  incision  that  will  hold  it  up  at  equal  distance  without  either 
twisting  the  kidney  or  going  through  the  pleura,  the  eleventh  intercostal  space, 
or  the  corresponding  rib;  therefore,  as  the  object  of  nephropexy  is  to  anchor 
the  kidney  as  near  as  pos- 
sible to  its  normal  posi- 
tion, it  is  better  to  put  but 
one  fixation  suture  through 
the  inner  side  of  the  in- 
cision. The  ends  of  each 
fixation  suture  are  clamped 
together  and  are  allowed 
to  hang  over  the  side  of  the 
body  until  further  needed. 

The  kidney  is  then  de- 
livered   in    the    manner    al-  Fig.  344.— Operation  for  Movable  Kidney.    The  kidney  is  then 

ready  described.     A  movable         '^^^^^'f  f]f}^f  ^hole  of  the  fatty  capsule  behind  the  kidney 
'^       _  and  halt  of  it  m  front  of  the  organ  is  cut  away.    (After  Ashton.) 

kidney  is  easily  delivered  on 

account  of  its  long  pedicle.  The  operator  can  often  simply  lift  it  out  of  its  fossa 
by  grasping  the  fatty  capsule  on  either  side  and  pulling  the  organ  first  downward 
beneath  the  iliac  crest  and  then  shooting  the  upper  pole  over  the  twelfth  rib  to 

the  surface  of  the  body,  after  which 
the  lower  j)ole  is  delivered. 


Fig.  345. — Operation  for  Movable  Kidney. 
The  capsula  propria  of  the  kidney  is  then  nicked 
in  the  middle  of  its  convexity  and  a  grooved 
director  is  pushed  beneath  it  up  as  far  as  the 
upper  pole,  after  which  it  is  cut  through.  The 
capsule  is  then  slit  in  the  same  way  down  to 
its  lower  pole. 


Fig.  346. — Operation  for  Movable  Kidney. 
The  kidney  capsule  on  the  back  of  the  kidney 
is  then  reflected  halfway  to  the  hilum  by  gently 
drawing  it  down  with  thumb  forceps  until  half 
of  the  posterior  surface  is  l^are.  The  capsula 
propria  over  the  anterior  surface  of  the  organ 
is  not  disturbed. 


In  twenty-five  per  cent  of  the  cases  I  operated  upon,  the  kidney  was 
markedly  enlarged;  ten  per  cent  were  lobulatcd  and  indurated.  In  some  cases, 
the  hepatic  flexure  and  the  ascending  colon  Avere  adherent  and  accompanied  the 
kidney  on  its  excursions.  Adhesions  to  surrounding  tissues  were  present  in  a 
number  of  patients.  The  separation  of  adhesions  and  the  decapsulation  caused 
varying  amounts  of  hemorrhage  in  the  dift'erent  cases. 


586 


OPERATIVE    SURGERY   OF   THE   KIDNEY 


The  whole  of  the  posterior  side  of  the  fatty  capsule  on  the  posterior  surface 
of  the  kidney  should  then  be  cut  away  and  about  one  half  of  its  anterior  surface 
(Fig.  344). 

The  eapsula  propria  should  now  be  split  from  pole  to  pole  over  the  convex- 
ity by  making  a  small  incision  through  it  and  then  passing  a  grooved  director 
beneath  it  as  far  as  the  upper  pole  and  cutting  through  the  capsule  on  to  the 
groove  with  a  knife.  The  cut  is  also  made  down  to  the  lower  pole  in  the 
same  way. 

The  posterior  capsule  is  reflected  down  toward  the  pelvis  until  one  half 
of  the  organ  is  decapsulated.     The  eapsula  propria  over  the  anterior  part  of  the 

organ    should    remain    intact 
(Fig.   346). 

The  explanation  of  this 
is  as  follows :  Over  the  pos- 
terior surface  of  the  kidney, 
no  fatty  capsule  is  needed, 
as  it  will  prevent  the  kidney 
from  adhering  and  growing 
to  the  posterior  abdominal 
wall.  The  eapsula  propria 
is  reflected  back,  because  it 
enables  the  kidney  tissue 
to  come  in  closer  contact 
with  the  posterior  abdominal 
wall  and  to  form  a  firmer 
union. 

The  anterior  surface  of 
the  capsule  is  not  reflected 
because  it  is  not  desired  to 
have  the  anterior  surface 
become  any  more  adherent 
to  the  soft  tissue  than  is 
natural.  The  anterior  layer 
of  the  fatty  capsule  is  half 
dissected  away  to  prevent 
a  redundancy  which  might 
overlap  the  convexity  of  the 
kidney  and  interfere  with  the  adhesion  between  the  posterior  wall  of  the  kidney 
and  the  abdominal  wall. 

The  sutures  ;N'os.  1,  2  and  3,  which  have  already  been  passed  through  the 
walls  of  the  incision,  are  now  passed  through  the  capsule.  No.  1  is  passed 
through  the  posterior  layer  of  the  eapsula  propria,  both  the  reflected  layer 


Fig.  347. — Operation  for  Movable  Kidney.  The  posterior 
fixation  sutures  are  passed  through  the  doubled  capsule  of 
the  kidney. 


EXPLORATIONS  AND  OPERATIONS 


587 


and  the  part  of  the  capsule  on  to  which 
(louhly  strong.  It  enters 
the  doubled  layer  of  cap- 
sule at  the  junction  of  the 
upper  and  middle  third, 
])asses  between  the  cap- 
sule and  the  kidney  pa- 
renchyma and  comes  out 
through  the  cajisulc  three 
(piarters  of  an  inch  be- 
low. Suture  ISTo.  2  is 
passed  through  the  two 
layers  of  capsule  just  be- 
low No.  1,  in  the  same 
way  (Fig.  347).  The 
fixation  suture  on  the 
inner  side  is  passed 
through  the  anterior  half 
of  the  kidney  capsule. 
It   enters    at   the   middle 


it  has  been  reflected,  thus  making  it 


Fig.  348. — Operation  for  Movable  Kid- 
ney. The  anterior  fixation  suture  is 
passed  between  the  capsule  and  cortex  of 
the  kidney,  as  indicated  by  dotted  lines, 
and  over  the  outside  of  the  capsule,  as 
is  shown  by  the  continuous  line. 


Fig.  349.— Operation  for  Movable  Kidney.  The  kidney  is  now  pushed  back  again  into  the  renal 
fossa  and  the  fixation  sutures  that  have  just  passed  through  the  renal  capsula  propria  are  again 
passed  through  the  abdominal  wall  half  an  inch  below  where  they  entered.  The  abdominal  waU  i? 
here  depicted  very  much  tliinner  than  it  should  be. 


588 


OPERATIVE    SURGERY   OF   THE   KIDNEY 


of  the  convexity  of  the  kidney,  between  the  anterior  layer  of  the  capsule 
and  the  renal  parenchyma,  and  passes  transversely  beneath  the  capsvde  for 
three  quarters  of  an  inch.  It  then  pierces  the  capsule  and  is  carried  down 
along-  its  outer  surface  for  three  quarters  of  an  inch,  where  it  again  pierces 
the  capsule  and  emerges  from  beneath  it  at  the  edge  of  the  convexity  agaiu 
(Fig.   348). 

The  kidney  should  now  be  pushed  back  into  its  fossa  again  with  the  free 
ends  of  the  sutures,  that  have  passed  through  the  abdominal  "wall  and  the  cap- 


FiG.  350. — Operation  for  Movable  Kidney.  The  muscles  and  fasciiE  of  the  abdominal  incision  are 
then  closed  by  interrupted  sutures.  The  fixation  sutures  are  hauled  taut  and  tied  over  the  ex- 
ternal layer  of  lumbar  fascia  and  the  skin  is  brought  together  over  them. 


sule,  clamped  aud  hanging  loo.^ely.  Then  the  free  ends  of  the  sutures  <tu  Xos. 
1,  2  and  3  are  threaded  on  Ilagedorn  needles  aud  passed  through  the  abdominal 
wall  from  within  outward  through  internal  fascia,  muscles  and  external  fascia 
(Fig.  349),  half  an  inch  beneath  the  point  at  which  they  were  inserted,  and  then 
the  two  ends  of  each  suture  are  clamped  together  again.  The  sides  of  the  in- 
cision are  then  sutured  together,  the  deep  fascia  sewed,  then  the  muscles  and 
the  superficial  fascia.     The  kidney  is  now  anchored  by  drawing  the  fixation 


EXPLORATIONS  AND  OPERATIONS 


589 


siitnros  taut  and  tyiii,<>'  their  ends  too-otlior   (Fig.  350).     This  should  he  done 
with  great  gentleuess  to  prevent  tearing  the  eapsule  or  distiirljing  the  relations 

with  the  posterior  abdominal  wall, 
which  are  exactly  correct  for  a  good 
apposition  (Figs.  351,  352,  353). 


Fig.  351. — Side  View  of  the  Convexity  after 
Anchoring  the  Kidney. 


SAXE,    'o2 

Fig.  352. — Sectional  Posterior  View  after 
Anchoring  the  Kidney.  /.  Posterior  fixa- 
tion suture.  la.  Anterior  fixation  suture. 
///.  Line  of  the  incision  union. 


After  the  abdominal  wall  has 
been  brought  together  and  the 
sntnres  tied,  the  skin  is  closed 
by  interrupted  sutures  tied  well 
to  the  outside  of  the  incision. 

After-teeatmext  of 
ISTephropexy.— In  order  to 
have  a  good  result,  the  patient 
should  lie  in  the  dorsal  position 
for  three  weeks  with  no  pillow 
under  the  head.  The  discom- 
fort of  not  changing  position  is 
very  great,  but  it  is  imperative 
-Anterior  View  AFTER  Anchoring  the  Kidney,  li  SUCCeSS  IS  desired. 


590  OPERATIVE  SURGERY  OF  THE  KIDXEY 

During  the  operation  for  nephropexy,  there  are  rarely  any  difficulties  en- 
countered. Sometimes  the  adhesions  between  the  capslila  propria  and  the 
kidney  are  so  great  in  places  that  small  pieces  of  renal  tissue  are  torn,  giving 
rise  to  hemorrhage.  This,  however,  can  he  easily  controlled  hy  hot  water  or 
peroxid  of  hydrogen. 

After  the  oj^eration,  there  is  often  a  reaction,  the  temperature  going  up 
to  101°  or  102°  F.,  which  generally  drops  to  normal  after  the  bowels  have 
moved. 

Occasionally  stitch  abscesses  form,  causing  a  slight  rise  of  temperature. 
The  suture  is  removed  from  the  affected  part,  the  wound  washed  out  with 
peroxid  and  a  wet  dressing  (bichlorid  solution)  applied.  The  temperature  then 
drops  and  the  wound  heals  uneventfully. 

I  have  had  but  one  case  of  deep-seated  abscess.  This  was  in  a  woman  who 
was  a  bleeder.  She  bled  continually  from  the  wound  for  three  days.  The 
bleeding  was  in  the  nature  of  an  oozing.  It  was  treated  by  injections  of  peroxid 
of  hydrogen  and  hot  water.  The  wound  was  then  packed.  It  later  became  in- 
fected, a  perinephritic  abscess  formed,  Avhich  was  opened  and  drained  and 
treated  as  a  collection  of  pus  elsewhere.  The  wound  healed  slowly  with  a  firm 
attachment  of  the  kidney  to  the  abdominal  wall.  Another  case  developed  a 
hematoma,  which  pressed  upon  the  ascending  colon  and  gave  rise  to  symptoms 
of  ileus.  These  disappeared,  however,  after  morphin  for  the  pain  was  given, 
followed  by  a  purgative.  For  further  information  see  chapter  on  Movable 
Kidney. 

Renal  Decapsulation. — I  shall  say  only  a  few"  words  regarding  renal  decap- 
sulation, as  I  have  considered  it  in  the  surgical  treatment  of  chronic  nephritis ; 
but  it  is  not  a  procedure  to  be  recommended,  as  my  experience  has  shoAm  me 
that  it  is  harmful,  rather  than  beneficial. 

The  steps  of  freeing  the  kidney  are  the  same  as  those  described  under 
nephropexy.  The  organ  is  decapsulated  in  the  same  manner,  excepting  that 
it  is  drawn  back  on  either  side  to  the  hilum,  after  which  the  entire  capsula 
propria  is  either  cut  aw'ay  by  scissors  or  else  it  is  rolled  up  around  the  pedicle 
and  left  there.  The  decorticated  kidney  is  then  replaced  in  its  fatty  capsule, 
from  which  it  is  supposed  to  obtain  an  additional  supply  of  blood  through  the 
extension  of  blood  vessels  from  this  capsule  into  the  substance  of  the  kidney. 
Results  have  shown  that  the  blood  supply  received  from  the  fatty  capsule  does 
not  increase  the  circulation  of  the  kidney  and  that  a  new  capsula  propria  forms 
which  compresses  the  organ  much  tighter  than  did  the  original  one.  The  opera- 
tion has  now  but  few  supporters  either  in  this  country  or  in  Europe. 

Nephrotomy. — The  incision  is  through  the  convexity  of  the  kidney  into  the 
pelvis.  Xephrotomy  is  the  operation  yar  excellence  in  nephrolithiasis.  It  is 
also  a  valuable  operation  in  hemorrhagic  and  neuralgic  nephritis,  and  in  all 
cases  of  suppurative  kidney  requiring  drainage. 


EXPLORATIONS  AND  OPERATIONS 


591 


Technique. — Before  performing  a  neplirotoiny  (m  an  organ  that  has  been 
delivered,  it  is  well  to  clean  up  quite  thoroughly  the  ureter  and  the  vascular 
pedicle,  and  to  separate  them  from  each  other.  I  generally  find  the  ureter  first, 
as  in  the  case  of  exploring  the  kidney,  and  then  clean  it  with  gauze  up  to  the 
pedicle;  after  which,  I  pass  my  forefinger  behind  the  vessels  of  the  pedicle  and 
free  them  from  the  surrounding  tissues  by  wiping  them  with  gauze. 

The  pedicle  should  be  controlled  while  the  incision  through  the  parenchyma 
into  the  pelvis  is  being  made.     This  can  be  done  by  an  assistant  hooking  his 


Fig.  354. — Nephrotomy.  In  performing  nephrotomy  the  same  position  and  loin  incision  is  used. 
In  all  cases  of  nephrotomy  the  ureter  is  delivered  and  separated  from  the  vascular  pedicle,  palpated, 
and  has  a  traction  suture  placed  about  it.     The  vascular  pedicle  is  then  compressed  by  an  assistant. 

forefinger  about  the  vessels  and  then  flexing  it  tightly  in  case  there  is  sufficient 
space ;  or  if  there  is  not,  placing  the  tips  of  the  fore  and  middle  fingers  on  one 
side  of  the  vessels  of  the  pedicle  and  the  thumb  on  the  other  and  then  compress- 
ing them  (Fig.  354).  I  sometimes  place  a  rubber  band  around  the  vessels  and 
tighten  it.  A  round  band  is  the  best,  as  a  flat  one  is  liable  to  cause  traumatism. 
Having  placed  it  about  the  pedicle,  I  am  in  the  habit  of  grasping  it  with  for- 
ceps and  twisting  it  until  the  pressure  is  sufficient  to  cut  off  the  blood  supply. 
Clamps  padded  by  rubber  tubing  can  also  be  used,  but  I  am  always  afraid  of 
injuring  the  vessels  by  too  much  pressure. 

After  the  blood  supply  has  been  shut  off,  the  kidney  is  grasped  at  one  pole 
between  the  thumb  and  forefinger  of  one  hand,  w^hile  the  assistant,  if  desired, 
steadies  the  other  pole  in  such  a  way  that  the  organ  is  held  in  a  straight  posi- 


592 


OPERATIVE    SURGERY    OF    THE    KIDNEY 


tion.  An  incision  is  then  made  throiigli  the  parencl}yma  into  the  pelvis.  This 
should  be  made  a  little  nearer  the  posterior  portion  of  the  convexity  than  the 
anterior,  as  then  there  is  less  danger  of  wonnding  the  vessels.     It  can  be  a  long 


fiG.  355. — Nephrotomy;  the  Long  Incision  from  Pole  to  Pole,  a  Little  Nearer  the  Posterior 
Portion  op  the  Convexity  than  the  Anterior.  It  gives  a  better  view  of  the  interior  of  the 
kidney  and  its  pelvis. 

incision  from  pole  to  pole  (Fig,  355),  or  a  short  one  between  the  poles  (Fig, 
356).  In  the  former  case,  a  better  view  of  the  interior  of  the  kidney  and  its 
pelvis  is  given ;  whereas  in  the  latter,  it  is  only  sufficiently  large  to  palpate  the 

interior,  which  would  be  neces- 
sary for  the  detection  of  a  cal- 
culus or  for  the  drainage  of  a  pus 
-  kidney.  The  best  rule  for  the 
short  incision  is  to  divide  the 
convexity  of  the  kidney  into  three 

Fig.  356.— Nephrotomy;  the  Short  Incision  between  parts  transversely  and  then  to 
the  Poles.  It  is  only  sufficiently  long  for  palpating  make  an  incision  1^  incheS  long, 
the  interior  of  the  kidney  and  its  pelvis  or  for  drainage.     ,        .  .  "... 

havnig  its  center  at  the  junction 
of  the  lower  and  middle  third  of  the  organ.  This  incision  should  be  5  milli- 
meters posterior  to  a  vertical  line  drawn  through  the  middle  of  the  convexity. 
After  the  incision  has  been  made  down  to  the  pelvis,  the  tip  of  the  finger  should 
be  introduced  into  the  pelvis  and  the  calices,  and,  Avith  the  fingers  of  the  other 
hand  on  the  outside  of  the  kidney  and  ureter,  a  very  complete  examination  of  the 
organ  can  be  made.  The  ureter  should  then  be  catheterized  from  the  renal  pel- 
vis down  to  the  bladder  to  see  if  there  is  any  impediment.  Calculi  can  some- 
times be  detected  by  downward  catheterization  which  had  not  been  noticed  when 
the  ureter  had  been  catheterized  from  below  upward  (Fig.  357). 


EXPT-OrtATlONS    ANT)    OPEPtATTOXS  593 

In  case  of  a  kidney  willi  an  apjiavently  liealtliy  parenelijma,  it  is  advisalile 
to  cut  through  as  little  as  possible  of  it,  as  the  sutures  that  are  employed  to 
close  it  cause  some  traumatism  in  their  passage ;  besides  which,  the  pressure  on 
the  renal  tissue  required  to  hold  the  sides  of  tlie  wound  together  tends  to  inter- 
fere witli  the  circuhition  in  tlie  cortex.  In  any  case,  if  it  is  necessary  to  thor- 
oughly inspect  the  wound,  an  incision  along  the  entire  convexity  should  be  made, 
although  this  would  give  rise  to  more  hemorrhage.  With  the  best  conservative 
measures  which  we  have  at  present  for  compression  of  the  pedicle,  there  is  al- 


FiG.  357. — Nephrotomy;  Catheterization  of  the  Ureter.     The  ureter  should  be  catheterized  from 
the  renal  pelvis  to  the  bladder,  to  see  if  there  is  any  impediment  present. 

ways  some  hemorrhage,  and  the  first  gush,  when  the  kidney  empties  itself  may 
be  sufficient  to  wash  out  a  small  stone  as  Avell  as  to  disguise  somewhat  the  char- 
acter of  the  surface  that  we  are  inspecting.  Sometimes  we  feel  by  the  small 
incision  an  induration  that  resembles  a  stone  and  make  the  longer  incision  and 
find  nothing  but  a  node  of  fibrous  tissue.  The  small  incision  is  usually  sufficient 
for  examination  and  drainage. 

Treatment  of  the  Renal  Incision. — This  depends  upon  the  causes  for 
which  nephrotomy  is  performed.  When  it  has  been  performed  simply  for  ex- 
ploration, if  nothing  has  been  found,  a  specimen  of  the  kidney  tissue  should  be 
taken  to  examine  for  tumor  or  tuberculosis;  if  for  the  removal  of  stone,  the 
calculus  should  be  removed  with  a  forceps;  if  for  hemorrhagic  nephritis,  for 
an  aseptic  case  of  stone,  for  exploration,  or  in  fact  .for  any  condition  associated 
with  an  aseptic  kidney,  the  renal  incision  can  be  closed  immediately  after  the 
nephrotomy.  In  all  suppurative  cases,  however,  whether  the  operation  has 
been  performed  for  the  drainage  of  a  renal  abscess  or  of  a  pyonephritic  or  pyo- 


594 


OPERATIVE    SURGERY   OF    THE    KIDNEY 


nephrotic  kidney,  a  drainage  tube — either  a  large  single  tube  or  two  smaller  ones 
— should  be  inserted  through  the  renal  incision  into  the  ])elvis,  and  should  leave 
the  kidney  at  the  junction  of  its  middle  and  the  lower  third,  to  remain  as  long  as 
necessary  for  the  individual  case. 

Suturing  the  Kidney. — In  case  the  kidney  is  aseptic  as  well  as  the  urine 
coming  from  it,  the  incision  can  be  closed  by  interrupted  sutures.  I  use  sutures 
of  chromic  gut  ISTo.  2,  which  are  passed  through  both  sides  of  the  incision  £- 
of  an  inch  apart  and  1^  inches  from  the  margin  of  the  wound,  while  between 
these,  -}  of  an  inch  from  the  margin  of  the  incision,  another  row  of  interrupted 

sutures  ISTo,  2  plain  catgut  is  passed  and 
ligated  (Figs.  358  and  359). 


Fig.  358.  —  Method  of  Passing  Sutures  in 
Closing  the  Nephrotomy  Incision  in  the 
Kidney. 


Fig.  359.  —  Appearance  of  the  Kidney  afte 
Closure.  Sutures  should  not  be  tied  too  tig.  . 
as  it  injures  the  kidney. 


A  cigarette  drain  should  then  be  introduced  into  the  wound  in  the  loin  ;; 
far  as  the  kidney  and  allowed  to  remain  for  twenty-four  to  forty-eight  hour.- 

and  as  long  after  this  a- 
there  is  any  evidence 
urinary  leakage. 

If  there  is  an} 
found  in  the  urine  ct 
ing  from  the  diseased 
organ,  even  if  it  is  mi- 
croscopical, a  drainage 
tube,  ]S[o.  25  French,  soft 
rubber,  should  be  in- 
serted into  the  pelvis  of 
the  kidney  at  the  junc- 
tion of  the  middle  and 
lower  third  of  the  organ.  (See  Fig.  360.)  The  kidney  incision  should  then  be 
closed  up  to  the  tube  in  the  manner  just  described.  It  should  then  be  drained 
for  three  or  four  days,  and  the  kidney  pelvis  w^ashed  out  with  silver  solution 


'■•Jr 

Fig.  360.  —  Drainage  Tube  in  Position.  In  pus  cases  a  soft 
rubber  tube  should  be  inserted  into  the  renal  pelvis  and  pro- 
trude at  the  junction  of  the  lower  and  middle  third. 


EXPLOEATTOT^S    AND    OPEPtATTOXS  595 

1:1,000  III  (lie  iiioi'iiiiiii,'  drcssiiiii-  iiiid  willi  lidric-ncid  soliitidii  ;it  llic  cvciiin*!,- 
drcssiiiii'.  In  cjiso  extensive  siippnriil  idii  is  seen  ;it  the  <i|ier;i1  ion,  the  kidney 
should  be  drained  for  eight  days  and  washed  out  throngli  ihe  tnhe  in  the  same 
way.  It  may  even  be  wiser  to  drain  evei-y  kidney,  nsing  a  small  catheter  in  cases 
in  which  there  is  no  ])ns  in  the  ni'ine.  In  all  cases,  the  tnbe  shonld  be  attaclied 
to  the  kidney  ca])snle  by  plain  gnt  and  a  wick  or  cigarette  drain  should  be 
])assed.  by  its  side  to  the  snrface  of  the  ki(hiey.  Cases  withont  ]jns  are,  how- 
ever, very  rare  in  my  practice. 

Complications  during  and  after  ISTEniROTOMY. — The  complication  that 
causes  most  alarm  during  nephrotomy  is  hemori-Jiage.  This  has  often  been  very 
alarming  in  mj  own  cases,  especially  in  cutting  into  the  kidneys  of  eases  with 
hemorrhagic  nephritis  and  anurias.  If  the  vessels  of  the  pedicle  have  been 
well  grasped,  the  hemorrhage  is  controlled  when  the  kidney  is  opened  ;  bnt  when 
the  pressure  is  removed,  it  may  become  profuse.  It  is  usually  a  capillary  ooz- 
ing, although  sometimes  there  is  a  spurting  artery.  The  oozing  is  generally 
controlled  somewhat  by  hot  water  or  peroxid  of  hydrogen.  Adrenalin  is  some- 
times used  and  has  given  better  results  in  the  hands  of  others  than  in  my  oavu 
cases.  If  very  hot  water,  120°  to  130°  F.,  is  poured  into  the  kidney  and  its 
two  sides  are  immediately  grasped  and  held  together,  the  oozing  will  usually 
diminish  so  that  the  catheter  drain  can  be  inserted  into  the  pelvis  and  the  two 
sides  fastened  by  sutures,  as  already  described.  If,  after  suturing  the  kidney, 
the  bleeding  continues  and  the  operator  feels  worried  about  the  case,  I  suggest 
that  a  four-tailed  bandage  be  applied  for  a  few  hours.  This  measure  has  not 
been  considered  feasible  heretofore,  because  the  w^ound  could  not  be  closed  as 
it  should  be  after  the  operation  on  account  of  the  necessity  of  \',-ithdrawing'  the 
bandage.  An  admirable  device  of  Da  Costa  of  cutting  the  base  of  the  bandage 
in  two  and  then  sewing  pieces  together  with  plain  catgut,  wtdch  softens  and 
allows  the  bandage  to  be  easily  pulled  out,  has  greatly  overcome  this  difficulty. 

A  four-tailed  bandage  consists  of  a  piece  of  gauze  16  inches  long  and  8 
inches  wdde,  which  is  drawn  under  the  kidney  from  above  downward  in  such 
a  way  that  A  and  B  come  above  the  pedicle,  and  C  and  D  below  it.  Tails  B 
and  C  are  then  tied  together  on  the  middle  of  the  renal  convexitj^  and  .1  over 
one  pole  and  D  over  the  other,  thus  controlling  hemorrhage  by  pressure  (Fig. 
361). 

A  spurting  artery  is  sometimes  seen,  especially  when  the  long  incision  is 
made  in  the  kidney  from  the  extremity  of  one  pole  to  that  of  the  other  and 
extending  too  far  anteriorly  in  an  uneven  course.  Such  an  artery  should  be 
caught  and  ligated.  Often  the  ligature  will  not  remain  on  ;  in  which  case,  a 
ligature  should  be  passed  about  it  by  a  cnrved  round  needle  and  the  artery, 
inclnding  the  tissue  about  it  usually  on  one  side  of  the  incision,  should  be  ligated. 

Sometimes  the  clamping  and  ligating  of  the  artery  is  sufficient  to  stop  the 
hemorrhage,  and  dni'ing  tlu^  closing  of  the  kidney  the  suture  slips  off  and  no 


596 


OPERATIVE    SURGERY    OF    THE    KIDNEY 


Fig.  361  A. — Four-tailed  Bandage.  The  base  of  the  band- 
age has  been  cut  through  and  catgut  sutures  have  been 
passed  through  the  tails  A  and  B  and  tied.  Two  others 
are  passed  through  tails  C  and  D  and  not  tied.  The 
looped  parts  of  the  two  lower  sutures  are  pulled  out  and 
slipped  over  the  convexity  of  the  kidney  while  the  base 
of  the  bandage  is  being  pulled  by  its  concavity.  After 
the  bandage  is  in  place  the  loose  loops  of  the  sutures  are 
slipped  over  the  lower  pole  of  the  organ  and  tied  on  the 
concave  side  like  the  two  upper  ones. 


spurting  follows.      Tlio  (luestion   then  comes  up:   Should  the  kidney  sutures 
used  in  closing  the  kidney  be  removed  and  the  artery  be  sought  for  and  again 

clamped  and  ligated  ;  sliould 
a  claiii])  be  k'ft  on,  or  a  tailed 
banchige  be  ajoplied  'i  I  gener- 
ally do  nothing  but  pack 
some  gauze  on  either  side  of 
the  ki(hiey  and  close  the 
wound  up  to  the  drain,  in 
case  one  has  been  inserted 
into  the  organ,  according  to 
whether  the  case  is  asejitic 
or  septic.  I  put  on  a  light 
dressing  and  instruct  tlie 
house  surgeon  to  have  the 
pulse  taken  every  half  hour 
and,  in  case  it  increases  in 
rapidity  and  becomes  weak, 
to  notify  me ;  if  I  cannot  he 
found,  to  consider  it  as 
an  emergency  case,  to  give 
strychnin  gr.  -^  by  hypo- 
dermic and  a  pint  of  hot  salt 
solution  wdtli  2  ounces  of 
whisky  by  enema,  to  be  re- 
tained. Then,  in  case  the 
pulse  does  not  rapidly  im- 
prove, I  instruct  him  to  open 
the  wound,  Avithdraw  the 
packing  and  deliver  the  kid- 
ney. In  case  the  hemorrhage 
comes  from  the  part  of  the 
spurting  artery,  I  direct  him 
to  open  that  part  of  the  kid- 
ney incision,  clamp  the  artery 
and  then  either  pass  a  ligature  on  a  needle  about  it  and  ligate  it ;  or  clami?  it  and 
leave  the  clamp  on  for  forty-eight  hours;  or  put  on  a  four-tailed  bandage;  or,  if 
the  hemorrhage  is  very  bad  and  the  patient's  condition  critical,  put  a  clamp  on 
the  vascular  pedicle.  Then,  except  in  the  last  instance,  my  instructions  are  to 
close  the  kidney  again,  pack  gauze  about  it  and  return  it  to  its  fossa  and  bring 
the  sides  of  the  incision  in  the  abdominal  wall  together  by  straps  and  notify  me. 
On  visiting  the  hosj)ital,  I  would  then,  in  the  case  of  the  buried  ligature  or  the 


Fig.  361  B. — Four-tailed  Bandage  in  Place.  Tail  B  on 
one  side  is  then  tied  to  tail  C  on  the  other,  as  is  also  tail 
C  to  tail  D;  the  tied  ends  crossing  one  another  in  the  mid- 
dle of  the  convexity.  Tails  A  are  then  united  over  the 
upper  pole  and  tails  D  over  the  lower. 


EXPLORATIONS   AND    OPERATIONS  597 

(•lamp,  jiroliably  siiii])ly  close  tlic  abdominal  wound,  leaving-  sufficient  space  for 
the  kidiicv  drain  or  the  clamp  to  pi'otrndc.  Jn  the  third  instance,  I  would  in- 
spect the  kidney  and  withdraw  the  banchige  or  simply  loosen  it  and  leave  it  in 
phice  and  watch  the  result,  which  W(juld  prol)ably  be  favorable.  In  case  of  either 
the  clamp  on  the  artery  or  the  Ijandage,  it  w<juld  not  be  left  on  over  forty-eight 
hours.  In  the  fourth  instance,  that  is,  wdieu  the  renal  pedicle  had  been  clamped, 
1  would  do  a  nephrectomy. 

1  do  not  a])prove  of  packing  the  kidney  and,  in  case  it  is  done  for  henun*- 
rhage,  think  that  it  shoidd  only  be  done  for  oozing  and  not  for  a  spurting  artery. 
In  case  the  kidney  is  packed  for  hemorrhage,  I  think  that  a  four-tailed  bandage 
should  be  jilaced  about  the  kidney  and  that  it  should  be  brought  up  to  the 
opening  in  the  abdominal  w^all  and  held  there  in  a  sling,  thus  making  a  tem- 
])orarv  nephrostonw.  I  may  here  say  that,  although  I  have  given  the  directions 
that  I  have  just  mentioned  many  times  to  a  house  surgeon  and  have  been  ex- 
tremely anxious  about  many  cases  at  the  time  of  the  operation,  it  has  happened 
only  once  that  a  house  surgeon  has  reported  to  me  by  telephone  a  case  that  I 
thought  would  have  to  be  interfered  with.  In  that  particular  case,  he  opened 
the  wound  in  the  loin,  caught  a  spurting  artery,  stopped  the  hemorrhage  by  a 
buried  ligature,  and  then  closed  the  wound  again.  The  case  was  one  of  hemor- 
rhagic nephritis. 

Urinar}^  and  pus  sinuses  are  very  frequent  complications.  A  urinary  sinus 
usually  closes  in  from  three  to  six  weeks.  In  case  it  does  not,  a  ureteral  cathe- 
ter can  be  passed  up  into  the  renal  pelvis  and  retained  there.  If,  on  its  with- 
drawal at  the  end  of  a  week  or  two,  the  urinary  discharge  from  the  fistula  has 
not  decreased,  then  an  exjdoratory  operation  should  be  performed  to  see  if 
there  is  any  cause  for  the  interruption  of  the  flow  of  urine  do^vn  its  natural 
channel.  For  the  causes  of  such  a  condition,  see  the  chapters  on  Urinary  Re- 
tention in  the  Kidney,  Hydronephrosis  and  Movable  Kidney. 

A  suppurative  sinus  shows  that  a  destructive  process  is  still  going  on  in 
the  kidney  which  is  probably  the  seat  of  a  pyelo-nephritis  or  pyonephrosis.  The 
sinus  should  be  washed  out  with  silver  solution  1 :  1,000  and  drained  with  the 
object  of  having  it  close  from  the  bottom.  In  case,  however,  the  sinus  continues 
and  the  patient  is  losing  weight  and  strength  and  running  a  slight  temperature, 
an  operation  should  be  performed  to  see  wdiat  the  cause  of  the  continued  sup- 
]iuration  is  and  wdiat  the  probabilities  are  of  its  cessation.  This  may  be  due 
to  an  unabsorbed  suture,  to  a  concealed  stone  or  to  a  slow  suppurative  process 
from  other  causes.  It  usually  means  a  secondary  nephrectomy  and  it  is  not 
wise  to  allow  the  patient  to  continue  too  long  without  operation. 

Poor  Drainage. — After  a  nephrotomy  in  a  septic  case,  the  drainage  often 
diminishes  or  ceases  and  later  there  is  a  rise  of  temperature  and  other  symptoms 
of  pus  absorption.  In  such  a  case,  a  pocket  of  pus  has  formed,  or  the  tube  has 
been  passed  between  some  muscular  layers  or  muscle  and  skin,  instead  of  into 


598  OPKIiATIVK    SURGEKY    OF    TJIE    KIDXKY 

or  down  to  the  kidney.  The  foi'efin<>('r  should  llicu  be  inserted  into  the  wound, 
when  it  will  soon  strike  ii  reeent  line  of  cleavage  through  which  it  will  work 
its  wa}'  down  to  the  kidney  and  from  there  into  any  pocket  that  may  happen 
to  be  present.  Tn  case  the  wound  has  closed  and  Ihe  finger  cannot  be  worked 
down  to  a  pns  cavity,  an  incision  should  be  made  down  to  the  ])erinc])hritic 
region  and  an}'^  pns  pocket  present  should  be  drained. 

Jn  any  case  in  which  the  patient's  condition  is  impaired  after  a  nephrotomy 
and  in  which  a  slow  grade  of  sepsis  exists,  the  condition  of  the  two  kidneys 
should  be  ascertained  and,  if  the  organ  that  has  not  been  operated  upon  is 
healthy,  the  suppurating  organ  should  be  explored  and  any  cause  of  suppura- 
tion encountered  should  be  removed  or  corrected  if  possible;  in  case  it  is  im- 
possible, a  nephrectomy  should  be  performed. 

Nephrostomy. — This  means  an  incision  through  the  convexity  of  the  kid- 
ney into  its  pelvis,  that  is,  nephrotomy,  plus  the  stitching  of  its  two  sides  to 
those  of  the  incision  in  the  loins.  It  is  a  good  method  in  suppurative  cases  in 
which  the  kidney  has  to  be  packed;  or  when  it  is  very  much  destroyed,  as  in 
some  cases  of  calculous  pyonephrosis;  or  when  it  is  desirable  to  employ  per- 
manent renal  drainage  and  consequently  have  it  in  the  most  convenient  place  for 


Fig.  362. — Nephrostomy.     This  is  nephrotomy  plus  fixation  of  the  sides  of  the  kidney  incision  to 
those  of  the  abdominal  wall.     Note  the  approximation  of  the  kidney  wall  to  that  of  the  abdomen. 

inserting  a  tube.  Before  the  kidney  is  incised,  the  fatty  capsule  should  be  dis- 
sected from  it  for  about  an  inch  on  all  sides  of  the  area  in  which  the  incision 
is  to  be  made  so  that  the  kidney  will  be  in  close  apposition  to  the  abdominal 
wall.  The  short  or  long  incision  can  be  made  into  the  renal  pelvis,  after  which 
it  should  be  explored  in  the  same  way  as  in  nephrotomy.  Sutures  should  then 
be  passed  through  the  side  of  the  abdominal  wall  and  the  walls  of  the  kidney, 


J 


EXPLORATIONS  AND  OPERATIONS 


599 


two  on  each  side  and  one  at  each  end,  six  in  ;dl  f  Fi.i;.  302).  These  should  then 
be  pulled  taut,  which  will  bring  the  cavity  of  tlic  kidney  just  behind  the  mid- 
dle of  the  incision  in  the  loin.     The  sutures  shouhl  then  be  tied  ou  either  side 


Fig.  36.3. — Drainage  in  Nephrostomy. 
This  is  practically  the  same  as  in  nephrotomy.     One  or  two  tubes  are  used. 

and  the  incision  in  the  muscles  and  skin  brought  together  by  suture  above 
and  below  up  to  the  beginning  of  the  incision  into  the  kidney  on  either  side. 
The  kidney  should  then  be  packed  with  ganze.    After  the  hemorrhage  has  ceased, 


J^'iG.  364. — Drainage  by  Siphonage. 
Used  after  a  nephrotomy  or  nephrostomy  operation  by  bed  patients. 


600 


OPERATIVE    SUliGERY    OF    THE    KIDNEY 


the  gauze  should  be  removed  and  one  oi*  two  tubes  inserted  for  drainage  (Fig. 
363),  The  drainage  tube,  or  one  of  them  in  ease  two  are  present,  is  connected 
by  a  glass  tube  with  another  piece  of  tubing  extending  into  a  bottle  on  the  Hoor 
beside  the  bed  (Fig.  364).  The  bottom  of  the  bottle  should  be  about  one  quar- 
ter full  of  carbolic-acid  solution  to  facilitate  drainage  by  siphonage.  A  binder 
should  then  be  placed  about  the  body,  through  which  the  tube  protrudes. 

The  same  methods  of  closing  the  abdominal  wound,  of  inserting  drainage 
tubes  into  the  kidney  and  draining  the  wound  by  siphonage  after  operation  are 
employed  in  both  nephrotomy  and  nephrostomy. 

Peemanent  Drainage  after  Nephrostomy. — This  is  occasionally  em- 
ployed w^hen  there  is  obstruction  to  the  flow  of  urine  through  the  ureter  or  into 
the  bladder  on  one  side.  The  apparatus  devised  by  Watson,  and  recommended 
by  him  principally  in  nephrostomy  for  tumor  of  the  bladder,  is  the  prefer- 
able one. 


Fig.  366. — Cup-shaped  Shield  of  Watson's  Apparatus  for  Permanent  Renal  Drainage 
THROUGH  THE  LoiN.      (After  Ashton.) 


Fig.  365  shows  the  front  of  the  apparatus,  which  is  bell-shaped,  with  a 
rubber  ring  about  its  base  and  a  tube  through  its  center.  The  front  part  of  the 
tube  extends  into  the  kidney  pelvis,  whereas  the  outer  end  of  the  tube  con- 
nects with  a  tin  box  hanging  below  it  and  resting  on  the  back  of  the  pelvis 
of  the  affected  side.  The  urine  runs  through  the  tube  into  the  tin  box 
(Fig.  366). 


EXPLOKATIONS  AND  OPERATIONS 


601 


Nephrectomy. — Xcphroctomy  is  tlic  ojicrntion  for  tlu-  i-oiiiDvnl  of  a  kidney. 
It  is  a  much  more  serious  o])cratioii  than  nephrotomy  on  account  of  the  neces- 
sity of  cutting  the  renal  pedicle, 
as  this  procedure  may  result  in 
sudden  death  from  extensive 
hemorrhage  or  in  slow  death 
from  venous  leakage  after  the 
operation.  Death  may  also  oc- 
cur from  shock  in  a  few  hours, 
or  from  anuria  as  the  result  of 
an  acute  congestion  or  inflam- 
mation of  the  other  kidney,  due 
to  the  amount  of  extra  work 
suddenly  thrown  upon  it. 

This  is  the  operation  for 
every  case  of  tumor  of  the  kid- 
ney and  of  unilateral  tubercu- 
losis ;  also  for  cases  of  nephro- 
lithiasis in  which  the  organ  is  a 
mere  pus  sac.  It  should  also  be 
used  in  cases  of  ruptured  kid- 
ney in  which  the  organ  is  se- 
verely injured  and  incapable  of 
functionating ;  or  in  case  the 
hemorrhage  is  severe,  in  which  pj^  3gg 
latter  instance  it  becomes'  an 
emergency  operation. 

Technique. — The  freeing  and  delivery  of  the  organ  is  the  same  as  in  the 
operations  of  nephrotomy.  The  consideration  of  the  pedicle  is  most  important 
and  it  is  more  essential  in  this  operation  than  in  any  other  to  have  the  vessels 
well  cleaned  and  free  from  fat,  as  it  is  then  easier  to  pass  the  ligature  and  tie  it 
with  less  danger  of  slipping,  which  is  the  important  part  of  a  nephrectomy. 

The  forefinger  of  one  hand  should  be  passed  around  the  pedicle  to  steady  it 
and  the  outside  of  the  vessels  should  be  wiped  down  with  a  piece  of  wet  or  dry 
gauze  held  in  the  other  hand.  In  this  way,  an  expanse  of  clean  pedicle  will  be 
exposed,  making  it  much  easier  to  pass  the  ligature  between  the  vessels  without 
injuring  the  veins.  A  wide  curved  clamp  with  blades  one  and  a  half  inches 
long  should  be  placed  on  the  pedicle  in  front  of  the  ureter,  this  duct  having  been 
drawn  back.  The  clamp  should  not  be  closed  too  tightly,  as  making  too  much 
pressure  tends  to  increase  the  tension  in  the  vessels  of  the  pedicle,  to  bind  them 
together  more  tightly  and  thus  to  make  it  more  difficult  to  introduce  the  liga- 
ture carrier  between  the  vessels  without  tearing  them.      The  surgeon  should 


The  Metal  Receptacle  of  Watson's  Ap- 
paratus FOR  Permanent  Drainage  of  the  Kidney 
after  Nephrostomy.     (After  Ashton.) 


602 


OPERATIVE    SURGERY   OF   THE   KIDNEY 


always  remember,  in  placing  the  clamp  about  the  vascular  pedicle,  to  feel  about 
it  Avith  the  object  of  seeing  that  the  ureter  is  not  included,  as  this  would  tend 
to  make  the  pedicle  thicker  and  more  difficult  to  ligate  securely.  I  have,  on  a 
few  occasions,  caught  the  ureter  with  the  clamp  after  having  carefully  sepa- 
rated it  from  the  vessels.  In  fact,  in  beginning  to  perform  nephrectomies,  I 
frequently  ligated  the  ureter  and  vessels  together  without  ever  having  had 
a  mishap.  The  ligature  material  used  is  generally  chromic  gut,  but  this 
is  liable  to  slip,  as  the  blood  pressure  in  the  renal  artery  is  as  great,  if 
not  greater,  than  any  other  artery  in  the  body.  Braided  silk  is  the  safer, 
although  it  tends  to  leave  a  sinus  that  may  not  heal  for  several  months, 
but  it  is  better  to  have  a  sinus  remaining  than  death  from  operative 
hemorrhage. 

There  are  numerous  instruments  used  for  carrying  the  ligature  between  the 
vessels  of  the  pedicle.      The  curved  ligature  carrier  is  usually  employed  and 


Fig.  367.- 


-Method  of  Clamping  the  Pedicle  and  Passing  the  Pedicle  Ligatures  in 
Nephrectomy. 


is  pushed  through  behind  a  tight  clamp.  I  have  on  two  occasions  torn  the  vein 
in  this  way  and  I  prefer  to  pass  a  thin-bladed  artery  clamp  gently  between  the 
vessels  (Fig.  36Y).  An  assistant  then  inserts  the  ligature  into  its  jaws  on  the 
other  side,  in  such  a  way  that  I  can  pull  it  through  double,  cut  it  into  two 
pieces  and  ligate  the  vessels  on  either  side  (Fig.  368).  I  have  frequently  used 
a  pair  of  thumb  forceps  with  equal  satisfaction  and  also  an  aneurysm  needle. 
It  is  often  difficult  for  the  assistant  to  thread  the  aneurysm  needle  if  it  is 


EXPLORATIONS    AND    OPERATIONS 


603 


Fig.  368. — Nephrectomy;  Ligatures  in  Place  Ready 
TO  Tie. 


passed  imthreadcd,  Avlioreas  in  case  it  is  passed  threaded,  it  is  sometimes  equallv 
difficult  to  pick  nj)  the  ligature  on  flic  (tthci-  side. 

If  possible,  there  must  he  sutHcieiit  space  left  hetween  the  clamp  and  the 
kidney  to  cut  through  without  injuring  the  organ  or  its  pelvis.  When  I  have 
considerable  space,  I  put  an- 
otlicr  clamp  on  the  vessels 
above  the  first  one  and  cut  be- 
tween the  two  after  having 
ligated  the  vessels  by  means  of 
a  square  or  surgeon's  knot.  I 
Ivdxe  the  ends  of  the  ligatures 
long. 

Immediately  after  the  vas- 
cular pedicle  has  been  cut 
through,  if  I  have  not  already 
ligated  and  cut  through  the 
ureter,  as  I  frequently  do,  I 
swing  the  kidney  out  of  the  in- 
cision until  it  hangs  over  the  patient's  back,  attached  to  its  ureter,  while  I 
inspect  the  ligated  pedicle.  I  sometimes  grasp  the  vascular  ends  of  the  pedicle 
with  artery  forceps  and  reinforce  the  double  suture  already  tied  by  another 

nearer  the  spine  (Fig.  369). 
The  pedicle  stump  must  be 
handled  wdth  great  gentleness. 
Very  frequently  in  the  ex- 
citement of  cutting  away  the 
kidney,  the  operator  pushes  a 
j)iece  of  gauze  with  force  into 
the  wound  on  account  of  some 
bleeding  and  in  this  way  de- 
taches the  ligature,  thus  giv- 
ing rise  to  more  hemorrhage. 
It  is,  therefore,  important  to, 
dry  the  wound  with  small 
pieces  of  w^et  gauze  on  a 
sponge  holder  and  never  to  use 
a  piece  of  dry  gauze  in  this 
area.  It  is  also  advisable  to 
make  no  traction  on  the  pedicle 
ligatures,  but  simply  to  use  them  as  guides  to  the  stump  of  the  pedicle.  I  nearly 
lost  one  patient  through  holding  the  pedicle  ligatures  while  I  turned  for  a  pair 
of  scissors.     The  body  of  the  patient  rolled  over  slightly,  making  traction  on 


Fig.  369. — Nephrectomy;  Second  Ligature.  The  kidney 
having  been  removed,  it  is  often  advisable  to  place  a 
second  ligature  above  the  first,  provided  the  pedicle  is 
sufficiently  strong. 


604  OPERATIVE    SURGERY   OF   THE   KIDNEY 

the  sutures,  rcsultiuii,-  in  one  slipping-  otf  and  giving  rise  to  a  terrific  hemor- 
rhage. After  cutting  through  the  pedicle,  the  sides  of  the  incision  should  ho 
retracted  and  the  stuiii])  df  the  pedicle  gently  sponged  ^vith  a  very  small  piece 
of  moist  gauze  on  a  sponge  holder. 

IlEMOKKirAGE. — The  treatment  of  bleeding  is  one  of  the  most  trying  com- 
plications that  a  surgeon  has  to  encounter.  It  is  usually  due  to  the  -wounding 
of  a  vein  during  the  passing  of  the  ligature.  If  a  bleeding  point  is  present,  it 
can  usually  be  seen  and  grasped  with  a  pair  of  fine  curved  forceps  and  ligated 
with  catgut  without  difficulty.  Another  cause  of  trouble  in  ligating  a  pedicle, 
is  through  placing  a  second  ligature  over  the  original  one,  which  may  loosen 
the  first  one  and  render  both  ligatures  less  effective.  Any  slight  oozing  can  be 
controlled  by  packing  gauze  into  the  renal  fossa.  If  there  is  a  profuse  hemor- 
rhage, then  a  hot  wet  gauze  pad  must  be  immediately  pushed  into  the  wound 
and  taken  out  quickly  and  the  bleeding  point  sought  for,  clamped  and  ligated. 
In  case,  however,  a  large  amount  of  blood  suddenly  wells  up  into  the  operative 
field,  the  operator  must  thrust  the  forefinger  and  middle  finger  of  one  hand 
into  the  wound  with  their  backs  downward  in  an  endeavor  to  catch  the  stump 
of  the  pedicle  between  them  and  to  pass  a  curved  hysterectomy  forceps  beneath 
them  with  the  object  of  grasping  the  bleeding  vessels  and  stopping  the  hemor- 
rhage and  saving  the  patient's  life,  even  at  the  risk  of  grasping  peritoneum, 
duodenum,  colon  or  other  tissues.  After  stopping  the  hemorrhage  by  this  means, 
it  is  well  to  leave  the  clamp  in  place  or  else  the  same  mishap  may  recur. 

I  think  that  most  cases  of  hemorrhage  of  the  pedicle  are  caused  by  the 
operator  becoming  excited  and  wiping  the  wound  out  with  gauze  sponges  and 
clamping  the  pedicle  at  random,  thus  loosening  knots  that  would  otherwise  have 
held  sufficiently  well.  The  clamps  just  referred  to  should  be  left  on  the  pedicle 
for  four  days,  although  in  a  number  of  instances  two  days  have  proved  to  be 
sufficiently  long.  The  handles  protrude  from  the  wound  and  should  be  pro- 
tected by  gauze  pads  and  a  thick  wreath  of  cotton.  The  position  in  bed  of  the 
patient  who  has  clamps  on  the  renal  pedicle  is  lying  on  the  healthy  side.  The 
wrist  of  the  arm  corresponding  to  the  side  operated  upon  should  be  tied  to  the 
side  of  the  bed  which  the  patient  faces,  while  the  ankle  of  the  operated  side 
is  tied  to  the  other  side  of  the  bed,  to  prevent  the  patient  from  rolling  over  on 
the  back  while  asleep. 

I  may  here  say  that  nephrectomy,  OAving  in  some  cases  to  the  shortness  of 
the  vascular  pedicle,  to  the  diminished  ileo-costal  space,  to  a  large  amount  of 
fat,  or  to  other  causes,  may  be  considered  the  most  dangerous  operation  in  sur- 
gery. I  have  seen  more  surgeons  become  excited  during  this  operation  than  in 
any  other,  and  personally  I  have  never  felt  so  helpless  as  when,  owing  t*^  the 
slipping  of  a  ligature,  I  have  had  such  a  large  amount  of  blood  suddenly  well 
up  into  the  wound  that  I  expected  the  patient  to  die  immediately ;  but  up  to 
the  present  writing,  no  death  from  hemorrhage  has  occurred. 


EXPLORATIONS    AND    OPEKATTONS  G05 

Treatment  of  the  ITueter. — Tlic  next  slcj)  in  our  iicpliroctomy  opcrutif^n 
is  ciittiiii>'  lliroiit^li  tlic  ureter  to  wlridi  llic  kidney  is  liiiii<;iiii;'  ovcv  the  side  of 
tlie  body,  in  the  cases  in  which  it  was  not  cut  before  the  pcilidc  was  cut  through. 
]t  shonhl  in  this  instance  be  ligatecl  in  two  places,  leaving  a  s]jace  of  half  an 
inch  between  the  two  ligatnres,  and  then  cut  throngh.  In  case  the  organ  is  in- 
fected, the  renniining  end  shonhl  be  cauterized  witli  carbolic  nv  with  the 
Pacpielin  and  then  fastened  into  the  wound.  If  it  is  tuberculons,  the  same 
treatment  can  be  nsed.  In  case  it  is  extensively  diseased,  as  mnch  as  possible 
of  it  may  be  removed,  although  I  rarely  have  to  resort  to  this  procedure.  After 
nephrectomy  in  a  septic  case  or  one  of  tubercnlosis  of  the  kidney,  the  wonnd 
slundd  be  washed  ont  with  a  1 :  2,000  solntion  of  bichlorid  of  mercury  or  peroxid 
of  hydrogen.  It  is  prndent  to  leave  a  cigarette  drain  down  to  the  pedicle  for 
twenty-four  hours  and,  on  removing  it,  to  insert  a  small  catheter  through  the 
opening  and  again  wash  the  wound  out. 

Accidents. — Accidents  other  than  hemorrhage  from  the  pedicle  in  per- 
forming nephrectomy  are  opening  the  peritoneum  or  the  pleura;  hemorrhage 
from  an  accessory  artery ;  or  the  tearing  of  the  vena  cava. 

Wounding  tlie  Peritoneum. — This  is  usually  torn  through  accidentally  in 
freeing  the  kidney  that  is  very  adherent  to  the  surrounding  tissues.  In  this, 
case,  the  surgeon  may  see  through  the  tear  the  smooth  peritoneal  surface,  the 
omentum  or  intestine,  or  one  of  the  organs,  as  the  liver  or  spleen. 

In  aseptic  cases,  sponge  any  protruding  part  with  salt  solution,  replace  it 
and  close  the  peritoneum  with  plain  catgut  sutures.  In  septic  cases,  the  pro- 
ti'uding  part  should  be  washed  with  peroxid  of  hydrogen  and  later  with  salt 
solution,  before  returning  it  and  suturing  the  rent.  On  one  occasion  Avlien  the 
tear  was  small  and  nothing  was  protruding,  I  simph'  placed  a  piece  of  gauze 
over  the  tear  to  wall  it  off  from  the  operation  field  and  allowed  it  to  remain 
in  place  for  two  days  after  the  operation.  I  have  never  had  any  trouble  result 
from  opening  the  peritoneum,  although  in  one  septic  case  I  could  see  the  lower 
])art  of  the  lolje  of  the  liver  protruding. 

Opening  of  tJte  Pleura. — The  pleural  cavity  is  usually  opened  when  cutting 
n])  to  the  twelfth  rib  with  scissors  in  the  effort  to  make  the  incision  as  high  as 
])ossible.  The  accident  is  immediately  recognized  by  a  peculiar,  rough,  aspirant 
sound,  caused  by  the  sucking  of  air  into  the  pleural  cavity  and  its  discharge 
during  the  acts  of  inspiration  and  expiration.  I  can  remember  at  the  present 
writing  only  a  single  instance  in  which  I  cut  through  the  pleura  in  nephrec- 
(:nny,  although  I  also  did  it  in  a  case  of  hydatid  cyst  of  the  kidney,  in  which 
the  cyst  alone  was  operated,  and  in  a  case  of  movable  kidney.  In  these  cases, 
I  simply  closed  the  opening  by  a  continuous  suture  of  chromic  gut  and  do  not 
lliink  that  the  accident  had  any  bearing  on  the  result  of  the  operation. 

IlernorrJiage  from  an  Accef^sory  Artery. — Hemorrhage,  as  I  have  already 
mentioned,  is  the  most  trying  and  dangerous  accident  that  can  occur  in  nephrec- 


506  OPERATIVE    SURGERY    OF    THE    KIDNEY 

tomy.  It  sonietimes  comes  from  accessory  arteries.  These  iisnally  enter  the 
kidney  on  its  internal  Ijoi'dcr  at  the  npjjcr  or  lower  pole.  These  vessels  are 
nsnally  torn  through  and  bleed  while  the  surgeon  is  separating  the  fatty  capsule 
from  the  kidney.  The  bleeding  point  is  caught  by  artery  forceps  and  ligated. 
If  difficulty  is  found  in  stopping  the  hemorrhage  with  the  ligature,  the  latter 
should  be  passed  threaded  on  a  needle  and  the  artery  ligated  together  with  the 
fatty  tissue  through  or  along  which  it  passes.  In  case  this  is  not  sufficient, 
the  vessel  should  be  clamped  and  the  clamp  left  on  for  a  day  or  two. 

Hemorrhage  from  the  Vena  Cava. — Hemorrhage  from  a  tear  in  the  vena 
cava  occurs  very  rarely  and  usually  in  the  case  of  malignant  growths  of  the 
kidney  with  adhesions,  although  it  may  also  take  place  in  the  case  of  suppu- 
rative diseases,  as  in  pyonephrosis.  The  methods  used  to  stop  the  hemorrhage 
in  this  accident  have  been  tamponing ;  placing  f orcejjs  on  the  part  torn ;  suturing 
the  vena  cava ;  ligating  the  torn  area  by  a  lateral  ligature ;  and  finally  com- 
pletely ligating  it.  Strange  as  it  may  seem,  the  ligature  of  the  entire  vena 
cava  below  the  renal  arteries  has  been  employed  a  number  of  times  and  seems 
to  have  given  the  best  results,  the  return  circulation  taking  place  through  the 
azygos  and  vertebral  veins.  Gosset  and  Lecene  (Tnbune  medicale,  1904)  have 
shown  by  their  experiment  on  dogs  that,  v\dien  the  vena  cava  is  ligated  below 
the  renal  veins,  the  dog  stands  a  fair  chance  of  recovering ;  but  when  it  is  ligated 
above  them,  serious  kidney  lesions  take  place  and  the  result  is  fatal. 

Complications  after  jSTepheectomy. — The  complications  that  occur  after 
nephrectomy  are :  Anuria,  infection,  urinary  or  purulent  fistulas,  fecal  fistulas. 
Hemorrhage  occurs  sometimes  after  the  operation,  but  rarely  to  a  degree  suf- 
ficient to  require  more  than  to  remove  the  suture  in  the  abdominal  wall  and 
tampon  the  renal  fossa. 

Anuria. — I  am  led  to  believe  that  this  is  extremely  rare  and  will  not  occur 
if  we  assure  ourselves  before  the  nephrectomy  that  the  other  kidney  has  suffi- 
cient eliminating  power  to  earry  on  the  renal  function  after  the  operation. 
As  I  look  back  over  the  nephrectomies  that  I  have  performed  during  the  last 
seventeen  years,  without  making  careful  statistics  I  can  only  recall  three  cases 
dying  from  anuria  after  nephrectomy,  all  of  which  cases  occurred  before  Ave 
were  skilled  in  ureteral  catheterization  and  in  estimating  the  renal  function 
of  each  kidney.  One  of  these  was  a  case  of  tuberculosis  of  a  unilateral  kidney 
operated  upon  without  sufficient  study  or  observation,  another  was  a  case  of 
nephrolithiasis  associated  with  pyonephrosis  and  the  third  was  a  case  of  mul- 
tiple abscess  of  the  kidney — an  emergency  case.  The  case  of  unilateral  kidney 
died  eight  days  after  the  operation;  the. second  case  three  days  afterwards,  the 
autopsy  shoAving  acute  cloudy  sAvelling  of  the  remaining  kidney ;  the  third,  two 
days  after,  no  autopsy.  •■ 

Anuria  should  be  treated  medically  after  nephrectomy.  We  should  give 
salt  solution  (normal)  by  hypodermoclysis — 8  ounces  every  four  hours  if  the 


EXPLORATIONS  AND  OPERATIONS  607 

patient  has  lost  inucli  blood — as  well  as  a  high  cleansing  enema  of  salt  s(jlntion. 
Cups  over  the  kidneys  are  also  helpful.  Internally,  from  5  to  10  grains  of 
diuretin  should  be  given  every  three  hours  in  capsule,  or  theocin  gr.  j  every  hour. 

If  anuria  persists  for  three  days  after  a  nephrectomy,  a  nephrostomy  should 
be  performed  (m  the  reuuiining  kidney  and  injections  of  salt  sol ul ion  liv  hypo- 
dormoclysis  and  by  rectum  continued.  The  first  danger  signals  of  uremia  in 
these  cases  are  generally  headache,  twitchings  during  sleep  and  contractions 
of  the  pupils. 

Infection  of  the  Wound. — A  rise  of  temperature  to  100°  or  102°  F.  is  the 
usual  operative  reaction  and  does  not  mean  any  more  than  it  would  after  any 
other  kidney  operation.  It  lasts  from  a  few  days  to  a  week,  although  the  tem- 
perature usually  goes  down  or  to  normal  after  the  bowels  have  moved.  In  case 
it  does  not,  however,  it  would  be  advisable  to  examine  the  wound.  If  it  is  due 
to  a  stitch  abscess,  the  surgeon  should  take  out  the  stitches.  If  due  to  gauze 
having  been  left  in  the  wound,  it  should  be  removed,  the  wound  w^ashed  with 
peroxid  of  hydrogen  or  a  1 :  2,000  solution  of  bichlorid  and  a  wet  dressing  of 
bichlorid  applied  locally. 

Frequently  after  operations  on  suppurative  kidneys,  a  purulent  discharge 
continues  from  the  operative  field.  In  these  cases,  the  temperature  may  sud- 
denly go  up  and  it  will  be  noticed  that  the  drainage  has  stopped  or  diminished 
as  after  a  nephrotomy  operation.  The  forefinger  is  then  introduced  into  the 
wound  and  works  its  way  down  into  the  renal  fossa  and  finds  the  accumulation 
of  pus.  It  should  then  be  washed  out  with  peroxid  solution  and  a  drain  in- 
serted and  the  wound  allowed  to  close  from  the  bottom  up.  After  nephrectomy 
for  tuberculosis,  the  fever  may  be  due  to  a  tuberculosis  of  the  tissues  in  the 
renal  fossa  requiring  antiseptic  irrigations  and  drainage. 

Shock. — Avoid  shock  by  hastening  the  operation.  Determine  beforehand 
just  what  operative  procedure  will  have  to  be  done,  just  what  may  happen  and 
what  to  do  in  case  it  does  happen.  Have  everything  in  readiness.  Begin  as 
soon  as  the  patient  is  under  the  anesthetic  and  stop  the  anesthesia  as  soon  as 
possible.  Give  the  patient  -gL-  of  a  grain  of  strychnin  before  leaving  the  table 
and  a  pint  of  salt  solution  wath  2  ounces  of  whisky  by  enema  after  he  is  in 
bed ;  then  alternate  the  strychnin  and  the  hot  saline  enemas  every  four  hours 
until  the  danger  of  shock  has  passed  and  the  patient's  pulse  is  good. 

Suppurating  sinuses  are  due  to  silk  ligatures,  fungosities  and  abscess  cavi- 
ties above  or  below  the  pedicle.  In  tuberculous  cases,  the  walls  of  the  wound 
may  be  lined  with  granulations  or  tubercles. 

When  silk  ligatures  are  used,  the  ends  should  remain  long  and  protrude 
from  the  wound  and  they  can  then  be  twisted  off.  In  any  case,  however,  the 
ligatures  usually  come  away  within  three  months  and  the  sinus  heals.  In  the 
case  of  abscess  pockets,  they  should  be  opened,  washed  out  with  a  solution  of 
bichlorid,  nitrate  of  silver,  or  peroxid  of  hydrogen,  singly  or  alternating. 


608  OPEKATIVE    SURGERY   OF   THE    KIDNEY 

Tn  tubereiiloiis  cases,  curette  the  sides  of  the  wound  and  i-ciclc  wit]i  iodoform 
gauz«.     In  all  pus  eases,  good  drainage  must  be  kept  up. 

After  a  nephrectomy  of  any  variety,  if  infection  is  present  in  the  Avound, 
a  cigarette  drain  or  tube  should  he  |i;isscd  ddwu  to  Iho  kidney  stump  and  should 
be  attached  to  the  skin.     The  skin  is  closed  by  interru])ted  sutures. 

Secondary  Nephrectomy. — This  operation  is  performed  in  two  classes  of 
cases:  In  the  first  instance,  after  a  neiihrotomy,  performed  for  the  object  of 
drainage,  tuberculosis  or  any  suppurative  condition  of  the  kidney,  or  for  stone ; 
in  the  second  instance,  when  one  kidney  is  so  diseased  that  a  nephrectomy  is 
called  for,  but  the  condition  of  the  other  organ  is  not  sufficiently  good  to  carry 
on  the  work  of  renal  elimination.  In  this  second  instance,  the  diseased  kidney 
is  opened  and  nephrotomy  done  for  the  sake  of  drainage  and  with  the  expecta- 
tion of  removing  the  nephrotomized  kidney  as  soon  as  the  healthier  kidney  is 
able  to  do  the  Avork  of  total  renal  elimination. 

The  arguments  in  favor  of  and  against  secondary  nephrectomies  are  con- 
sidered in  the  various  chapters  of  renal  diseases.  It  is  never  used  in  tumor, 
sometimes  in  tuberculosis  and  suppurative  diseases  from  other  causes ;  but  in 
my  own  experience,  it  has  been  most  frequently  employed  in  renal  calculus. 

The  technique  of  secondary  nephrectomy  is  the  same  as  that  of  primary. 

Subcapsular  Nephrectomy. — This  operation  is  indicated  when  the  capsula 
propria  and  the  fatty  capsule  are  so  adherent  that  they  cannot  be  separated. 

The  united  capsules  should  be  cut  through  and  peeled  from  the  kidney  on 
either  side  as  far  over  the  pedicle  as  possible.  It  is  difficult  to  deliver  the  kid- 
ney because  the  pedicle  is  so  short  and  encumbered.  A  clamp  should  be  placed 
on  the  pedicle  and  a  heavy  braided  silk  ligature  placed  at  the  point  to  which  the 
capsules  have  been  peeled  back;  the  vessels  of  the  pedicle  are  cut  through  be- 
tween the  clamp  and  the  kidney,  after  which  the  clamp  is  removed,  although 
it  can  be  left  on  for  two  or  three  days  in  case  hemorrhage  is  feared.    • 

Another  method  is  to  free  the  ureter  immediately  after  decapsulating  the 
organ,  then  to  dissect  up  along  the  ureter  to  the  renal  pelvis,  cut  away  as  mucli 
as  possible  of  the  anterior  and  posterior  parts  of  the  united  capsules  and  search 
for  the  vessels  in  the  mass  of  adherent  fat  and  fibrous  tissue  in  front  of  the 
pelvis.  After  the  vessels  have  been  found,  they  should  be  freed  by  the  method 
already  described.  Renal  exploration  and  delivery  of  the  kidney  should  then 
be  attempted,  although  it  is  never  very  satisfactory.  The  pedicle  can  be  clamped 
proximal  or  distal  to  the  reflected  capsules,  depending  on  our  success  in  freeing 
the  pedicle.  In  either  case,  a  braided  silk  ligature  should  be  placed  on  the 
pedicle,  after  which  it  should  be  cut  through  between  clamp  and  pelvis.  The 
clamp  should  be  left  on  or  removed.  Sometimes  in  subcapsular  nephrectomies, 
the  renal  pelvis,  ureter  and  vessels  are  all  caught  in  one  ligature,  in  which  case 
there  is  liable  to  be  considerable  hemorrhage  on  cutting  through  the  mass,  as 
it  is  so  large  that  it  is  difficult  to  secure  it  firmly. 


EXPLORATIONS  AND  OPERATIONS 


609 


Albarran  strij).s  off  the  united  capsules,  inserts  the  lingers  of  one  hand 
nndei-  the  u])per  pole  and  those  of  the  other  hand  under  the  lower  pole  and,  by 
2)ulling  the  organ  down 
and  toward  the;  front  of 
the  body,  he  can  usually 
bring  the  kidney  into  sucli 
a  position  as  to  be  able  to 
seize  the  pedicle  by  a 
clamp  pushed  from  below 
upward.  In  many  cases, 
he  finds  it  impossible  to 
see  what  is  being  done  and 
is  guided  more  by  the  sense 
of  touch  in  placing  the 
clamp  on  the  pedicle  be- 
fore the  decorticated  kid- 
ney   has    been    delivered. 

The     kidney     is     then     cut      ^^^-  370. — Albarran's  Method  of  Securing  the  Pedicle  in  a 
,1  1        I  ,^  ^  Subcapsular  Nephrectomy. 

tln'ougli    above   the   clamp. 

The    stump    of    the    pedicle,    the    ureter    and    pelvis    remain    in    the    clamp. 

The    capsule    is    then    cut    through    below    the    stump    of    the    pedicle,    and 

the  ureter  found  and  fol- 
lowed up  to  the  vessels  of 
the  pedicle  and  the  capsule 
around  the  pedicle  is  then  cut 
through  (Fig.  370).  This  al- 
lows the  capsule  to  slip  back 
over  the  renal  vessels  toward 
the  aorta  and  vena  cava,  thus 
making  room  for  passing  the 
ligature  more  carefully  about  the 
renal  vessels  behind  the  clamp. 
The  ureter  is  then  ligated  sepa- 
rately and  cut  through,  and  the 
vessels  of  the  pedicle  as  well 
(Fig.  371).  The  end  of  the 
stump  of  the  pedicle  contain- 
ing the  remains  of  the  pelvis 
should  then  be  removed,  after 
which  as  nnicli  of  the  capsules 

as  possible  should  be  cut  away  with  scissors,  care  being  taken  not  to  attempt  to 

remove  too  much  in  case  of  firm  adhesions. 


Fig.  371.  —  Retraction  of  the 
Capsule,  Allowing  the  Op- 
erator to  Ligate  the  Pedi- 
cle Outside  of  It. 


610 


OPERATIVE    SURGERY   OF   THE   KIDNEY 


In  doing  subcapsular  nephrectomies  in  a  mass  of  adherent  fibrous  and  fatty 
capsules  and  tissues,  it  must  always  be  remembered  when  the  two  capsules  of 
the  kidney  are  adherent  and  cannot  be  separated,  that  the  ureter  should  be 
found  and  followed  up  to  the  renal  pelvis,  that  the  double  capsule  should  then 
be  pushed  down  to  the  pelvis  and  as  much  as  possible  of  it  removed  with  the 
scissors  on  all  sides,  thus  giving  more  room  for  our  work  on  the  pedicle.  A 
strong  silk  ligature  can  then  be  tied  about  the  pedicle  and  adherent  tissue  as 
far  from  the  kidney  as  possible.  The  kidney  can  then  be  split  vertically.  If, 
after  it  has  emptied  itself  of  blood,  the  bleeding  discontinues,  it  shows  that  the 
ligature  on  the  pedicle  has  shut  off  the  blood  supply.  If  the  bleeding  continues, 
another  heavy  ligature  or  a  clamp  can  be  applied  until  it  ceases.  After  the 
bleeding  has  ceased,  both  sides  of  the  kidney  can  be  cut  away  with  scissors. 

Partial  Nephrectomy. — This  means  the  removal  of  part  of  the  kidney.  It 
is  net  a  common  operation  and  is  usually  confined  to  one  pole  of  the  kidney. 
It  is  indicated  in  the  case  of  an  injury  or  malignant  growth.  This  is  also  an 
exceedingly  difficult  operation,  as  the  blood  vessels  on  the  sides  of  the  kidney 
are  quite  large  and  bleed  so  freely  that  they  are  difficult  to  control ;  besides 
which  it  is  not  easy  to  secure  a  good  apposition  and  firm  union  of  the  cut 
surfaces. 

The  organ  having  been  delivered,  it  should  be  carefully  held  and  the  pedicle 
firmly  compressed.  A  w^edge-shaped  piece  should  then  be  excised  from  the 
portion  of  the  organ  involved,  after  w'hich  its  edges  are  drawn  together  with 
sutures  of  jSTo.  2  chromic  catgut,  Avhich  should  be  inserted  1^  cm.  from  the  bor- 
der of  the  incision,  passing  through  the  deepest  part  of  the  renal  tissue,  15  mm. 
from  one  another,  before  the  pedicle  is  relieved  of  compression  (Fig.  372). 


Fig.  372. — Partial  Nephrectomy      Illustrating  the  manner  of  excising  a  portion  of  the  kidney  and 
uniting  the  sides  of  the  gap  that  is  left.     (After  Albarran.) 

Nephrectomy  by  Morcellement. — This  operation  was  made  popular  by  Pean 
when  renal  surgery  was  in  its  infancy  and  is  now  rarely  performed.  It  is  well, 
however,  for  a  surgeon  operating  on  the  kidney  to  be  familiar  with  all  the  meth- 
ods, as  he  might  find  himself  in  a  very  uncomfortable  position  in  attempting  to 


EXPLOEATIONS  AND  OPERATIONS 


611 


V 


.\\\ 


do  tlio  reo-iiliir  iicphrcctmny  operation  in  a  oaso  in  wliieli  tlic  snljcapsnlar  nephrec- 

toiiiv  or  niorcellcinont  was  indicated.     It  should  be  employed  in  rare  instances 

when  snbcapsnlar  nephrectomy  ""\ 

is    impossible    on    acconnt    of 

a    perinephritic    inflammation 

with   adhesions  of  the  fibrous 

and  fatty  capsule  to  each  other 

and  to  the  surrounding-  tissues, 

as  tlie  freeing  of  the  kidney  in 

these  cases  is  liable  to  produce 

serious  hemorrhage. 

Technique.  —  When    the  ;^; 
fibrous  and  fatty  capsule  can-  , 
not  be  sufficiently  freed  from 
the  organ  to  place  a  clamp  on 
the  pedicle,  the  kidney  should 
1)6     decapsulated     by     cutting 


.^-i;^Z2ZaZ222Z5RfeK55jj 


-y/^yyy/^' 


A'/ 


Fig.  373  A.  —  Nephrectomy  by  Mohcellement. 
The  lower  pole  amputated  below  a  straight  clamp 
K,  passed  transversely  across  the  kidney  at  the 
junction  of  the  lower  pole  and  middle  part  of  the 
organ,  and  a  curved  clamp  {Kl)  passed  below  it, 
compressing  the  vascular  pedicle.     (Tuifier.) 

-  hs  ^ 
^,^  through  the  comhined   capsules 

^  of  the  kidney  over  the  convex- 

ity by   a   vertical   incision   and 
^  jmshing    them    back    on    either 
'■'^  side.     The  lower  pole  of  the  kid- 

ney should  be  freed  and  a  pair  of 
strong  straight  forceps  applied 
transversel}^  with  a  sufficient  force 
to  shut  off  the  circulation  in  the 
lower  pole.  This  polo  should  then 
be    cut    away    beloAv    the    clamp. 

FIG.373B.-NEPHRECTOMY  BY  Mohcellement.  Th?  ^^  ^'"^"''^'^^  ^^^^^^P  should  thou  be 
upper  pole  amputated,  and  corresponding  clamps  passed  besids  the  detached  part 
A?  and  A'J7'«  s(7m.      (TufRer.)  p    i       t-i  i     ,        -,  ■, 

01  the  kidney,  and  should  gi'asp  as 
iimcli  as  possible  of  the  pedicle.  The  upper  pole  should  then  be  freed  as  well 
as  possible,  and  a  straight  clamp  applied  transversely  to  the  kidney  tissue  in 


612 


OPERATIVE    SURGERY    OF    THE    KIDNEY 


'S> 


\' 


such  a  way  as  to  shut  off  the  blood  supply  to  the  upper  pole.     The  upper  pole 
should  then  be  cut  away  above  the  clamp,  and  another  curved  forceps  should 

be  passed  by  the  remaining  stump  of 
the  up])er  polo  and  should  grasp  as 
much  as  possible  of  the  })edicle.  By 
these  maneuvers  tlie  blood  sup})ly 
has  been  shut  of!"  from  the  kidney 
by  the  two  curved  clamps  on  the 
pedicle  and  nothing  remains  of  the 
organ  but  an  area  of  kidney  tissue 
corresponding  to  the  space  between 
the  poles.  This  can  be  removed 
piecemeal  or  in  one  piece  after  de- 
taching the  straight  clamps.  A  liga- 
ture should  then  be  thrown  about 
the  pedicle  beyond  the  clamps  and 
ligated.  In  case  this  cannot  be 
done,  then  the  clamps  should  be  left 
on  from  two  to  four  days. 

Closing    the    Wound. — In    all 
the    operations    that    have    thus    far 
been  described,   the  curved   incision 
in  the  lumbar  region  with  the  pa- 
FiG.  373  C. — is[EPHRECTOMy  BY  MoRCELLEMENT.    St  tlcut  lying  ou  tlic  hcaltliy  lolu  has 

shows  the  remains  of  the  isthmus  between  the  two    ■,  ^         :i        rn  i   •       i         i 

poles  after  it  has  been  cut  down.      (Tuffier.)  ^^ecn  employed.      The  WOUud  IS  cloScd 

with  'No.  3  chromic  gut,  interrupted 
sutures  passed,  first,  through  the  deep  lumbar  fascia;  second,  through  the 
muscles  and  third, 
through  the  superfi- 
cial fascia  and  skin. 

The  drainage  tube, 
if  one  is  employed, 
as  is  generally  the 
case,  is  inserted  just 
below  the  twelfth  rib 
at  the  apex  of  the  kid- 
ney angle  down  to  the 
stump  of  the  renal 
pedicle.     It  should  be 

fastened    to    the    skin 

with    nlnin    oafa■^^f    cm  Fig. 374. — Closing  of  the  Wound  in  Nephrectomy  by  Morcellement. 

t    '                 to  -phg  muscular  and  fascia  layers  of  the  wound  are  closed  with  interrupted 

closing  the  wound.  sutures  of  No.  3  chromic  gut;  the  skin  also  by  interrupted  sutures. 


EXPLORATIONS  AND  OPERATIONS 


613 


Nephrectomy  by  the  Transverse  Incision. — This  is  made  in  a  transverse 
line  at  the  level  of  the  umbilicus  from  the  erector  spina?  musch'  to  the  rectus 
al)dominis  (Fig.  327).  The  patient  can  be  placed  on  the  healthy  side  or  on 
tJK^  back ;  the  latter  position  is  preferable  and  will  be  considered  here.  It  is 
well  to  have  a  log  or  sand  bag  beneath  the  patient  in  such  a  position  as  to 
stivlch  I  lie  il(M>lumbar  space  as  much  as  possible.  The  incision  is  popular 
in  cases  in  which  it  is  desired  to  ligate  the  pedicle  before  freeing  the  organ, 
although  it  can  be 
applied  whenever  a 
nephrectomy  is  to  be 
performed,  as  in  tu- 
berculosis or  tumor 
of  the  kidney.  It  is 
not  such  a  good  in- 
cision for  nephrot- 
omy, nephrostomy  or 
an  exploratory  op- 
eration and  is 
never  used  in  neph- 
ropexy. It  is  quite 
frequently  followed 
by  hernia. 

The  technique  is 
simple.  The  incis- 
ion is  made  through 
the  skin  and  muscu- 
lar wall  of  the  abdo- 
men and  its  fascia 
down  to  the  perito- 
neum. The  operator 
then  stands  on  the 
healthv    side    of   the 


Fig.  375. —  Nephrectomy  by  the  Tuansvehse  Incision.  The  kid- 
ney delivered,  the  muscular  wall  having  been  cut  through  and  the 
peritoneum  pulled  toward  the  median  line. 


patient  while  the  assistants  retract  the  wound  and  he  gradually  works  his 
hand  with  his  finger  tips  curved  in  the  direction  of  the  interior  abdominal 
wall  and  gently  separates  the  peritoneum  from  the  internal  fascia,  at  the 
same  time  drawing  it  with  its  contents  toward  the  median  line  until  the  fatty 
capsule  is  seen. 

An  assistant  then  holds  back  the  peritoneum  and  its  contents  toward  the 
healthy  side  and  the  surgeon  cuts  through  the  fatty  cajisule,  showing  the  kidney. 
The  organ,  ureter  and  pedicle  are  then  exposed  and  freed,  and  the  peritoneum 
with  its  contents  within  is  drawn  still  further  toward  the  healthy  side  and  the 
kidney  is  delivered    (Fig.   375).      The  vascular  pedicle   is   then  clamped   and 


614 


OPERATIVE    SURGERY   OF   THE   KIDNEY 


Fig.   376. —  Nephrectomy  by  the  Transverse   Incision.       The  vas- 
cular pedicle  clamped  after  the  ureter  has  been  pulled  to  one  side. 


ligated  by  the  same  method  as  has  already  l)eeii  outlined   (Fif>'.  370),  the  kid- 
nev   removed    and    the   ureter  lii>at('d   and    cut   throuiili.      The   diliertnit   layers 

III'  the  a  I)  (I  oui  i  ii  al 
wall  ai'('  closed  layt.-r 
by  layer  in  the 
same  way  as  after 
the  othci'  luDiliar  in- 
cisions. 

Anterior  or  Trans- 
peritoneal Nephrec- 
tomy.— This  opera- 
tion is  generally  per- 
formed in  cases  of 
tumor  of  the  kidney, 
especially  in  chil- 
dren, in  cysts  of  the 
organ  and  hydro- 
nephrosis, as  it  is 
snpposed  to  give 
more  space.  The  ])a- 
tient  is  placed  in 
the  dorsal  position,  with  something  imder  the  back  as  already  described 
in  the  preceding  operation.  A  ver- 
tical incision  is  made,  extending 
down  along  the  outer  border  of  the 
rectus  abdominis  muscle,  through 
the  skin,  muscular  wall  and  perito- 
neum (Fig.  326).  The  intestines 
and  colon  over  the  kidney  are  drawn 
toward  the  healthy  side ;  the  wound 
is  widely  retracted  and  the  intestines 
are  well  walled  off  with  abdominal 
pads.  This  gives  a  good  view  of  the 
outer  layer  of  the  mesocolon  through 
Avhich  the  incison  is  made  without 
hemorrhage,  as  the  blood  vessels  go- 
ing to  the  colon  are  in  the  inner 
layer  of  the  mesocolon.  The  cut 
along  the  outer  border  of  the  colon 
is  about  an  inch  from  it  and  is  con-  Fig.  377.— Anterior  or  Transperitoneal  Ne- 
tinued     for     a     sufficient     distance     to  phrectomy.      The  peritoneal  cavity  opened  and 

an  incision  made  through  mesocolon  on  the  outer 

deliver     the     kidney     (Fig.     377).         side  of  the  fat. 


EXPLORATIONS  AND  OPERATIONS 


615 


The  fat  about  the  kidney  can  easily  be  seen  and,  wlicii  (■iit  thron"h  shows 
Ihc  ki(hiey.  The  fatty  capsule  is  pushed  away  from  the  posterior  surface 
of  the  (jroan  and  then  from  the  anterior,  care  being  taken  in  the  latter  case 
not  to  injure  the  blood  vessels.  The  adhesions  are  sometimes  very  dense 
and  have  to  be  clamped  and  li- 
gated  as  in  doing  extraperito- 
neal operations  (Fig.  378). 
The  kidney  is  then  delivered 
and  the  pedicle  is  clamped, 
ligated  and  cut  through,  and 
the  kidney  is  removed  in  the 
same  manner  as  in  the  trans- 
verse incision  (Fig.  379).  By 
increasing  the  incision  down- 
ward, the  haiiphatic  glands 
can   be   seen   and   removed   in 


Fig.  378. — Antebior  or  Transperitoneal  Nephrec- 
tomy. The  kidney  being  freed  from  the  fatty  cap- 
sule after  the  posterior  parietal  peritoneum  has  been 
opened. 

malignant  cases.  The  peritoneum  is  then 
closed  with  I^o.  2  plain  catgut  posteriorly 
and  anteriorly,  the  fascia  and  the  mus- 
cular wall  are  closed  with  ]^o.  3  chromic 
gut  and  the  skin  with  plain  gut,  chromic 
gut  or  silkworm  gut  as  preferred.  In 
case  drainage  is  indicated,  an  incision 
should  be  made  through  the  loin  from 
Avithin   outward,    just   below    the   twelfth 

t'lG.  379.  —  Anterior  or  Transperitoneal      rib    and     along    the    quadratus    luuihorum 
Nephrectomy.       The    kidney    delivered-  ,,^   i         •         i-i         i  "j  j.    •  i  i 

the  pedicle  clamped  and  ligated.  •     "^"^^^^^    '''    ^^^^    Sidney    triangle,    and    a 

drainage  tube  should  be  pushed  through 
before  closing  the  peritoneum  posteriorly.  After  the  operation,  the  dressing 
should  bo  performed  through  the  loin  incision,  as  in  the  case  of  an  operation 
throuiih  the  loin. 


616 


OPERATIVE    SURGERY    OF    THE    KIDNEY 


In  some  patients  it  is  considered  desirable  to  drain  from  in  front,  in  which 
case  the  internal  anterior  and  posterior  layers  of  peritoneum  are  sewed  together 

as  are  the  external  anterior  and  posterior  layers. 
This  leaves  a  space  down  to  the  renal  fossa  through 
which  a  drainage  tnbe  is  passed.  The  perito- 
neum, muscular  wall  and  skin  are  then  sutured 
individually  up  as  far  as  the  tube  and  a  strip  of 
gauze  is  inserted  on  either  side  of  the  tube 
(Fig.  380). 

Operations  for  Uronephrosis  and  Uropyone- 
phrosis. — Uronephrosis  (hydronephrosis)  and  uro- 
pyonephrosis  are  usually  due  to  an  improper  rela- 
tion between  the  pelvis  and  the  ureter.  They  may 
also  be  due  to  nephroptosis  and  to  numerous 
other  causes,  among  which  are  abnormalities  of  the 
ureter. 

The  blood  vessels  may  be  irregular  in  their  dis- 
tribution and  their  relations  to  one  another.  Ab- 
normal branches  of  arteries  may  exist,  acting  as 
strands  (cords)  on  which  the  ureters  double  when  a 
movable  kidney  fills  with  urine  and  falls  over  them. 
If  such  a  branch  is  cut  to  afford  relief  to  the  kidney, 
necrosis  might  take  place  in 
the  part  of  the  organ  sup- 
plied by  the  branch.  Small 
vessels  going  to  adhesions 
can  safely  be  cut. 
In  hydronephrosis,  the  small  pockets  are  first  a  part 
of  the  pelvic  cavity;  later  the  kidney  tissue  becomes 
atrophied,  and  large  pockets  form.  These  enlarge- 
ments usually  take  place  first  in  the  lower  part  of  the 
renal  pelvis,  then  in  the  central  and  upper  portions, 
corresponding  to  the  two  principal  divisions  of  the 
pelvis,  resulting  in  an  enlargement  of  the  pelvis  as 
well    as    all    the    calices    entering    into    it.     At    other 


Fig.  380. — Anterior  or  Trans- 
peritoneal Nephrectomy. 
The  kidney  removed,  the 
wound  closed,  and  the  drain- 
age in  place. 


times  it  is  simply   a  bag  in  which  but  little  kidney 


Fig.  381. — Hydronephrosis. 
It  is  apparent  that  the 
lower  part  of  the  dilated 
sac  cannot  drain  through 
the  ureter  and  that  reten- 
tion of  urine  takes  place 
there. 


tissue  is  recognized.  The  amount  of  fiuid  in  hydro- 
nephrosis varies  from  a  few  grams  to  a  few  liters  (Fig. 
381). 

Opeeative  Treatment. — The  variety  of  operation 
for  uronephrosis  depends  upon  (a)  whether  the  ureter  is  of  good  size  and  per- 
meable;  or  (&)  strictured,  or  (c)   impermeable. 


EXPLOKATIONS  AND  OPERATIONS 


617 


(a)  When  the  ureter  is  of  good  size  and  permeable,  we  must  notice  whether 
or  not  the  ureteral  orifice  is  normal  and  at  the  lowest  point  of  the  pelvic  pouch 
and  draining  its  cavity  thoroughly;  or  whether  it  is  placed  too  high  and  con- 
sequently makes  a  spur,  damming  back  the  urine.  If  it  is  not  so  placed  as  to 
drain  the  pelvis  well,  it  is  necessary  to  (1)  do  a  nephropexy,  (2)  resect  perhaps 
a  portion  of  the  pouch  below  the  ureter,  (3)  perform  a  capittonage  operation, 
and  reef  or  tuck  up  the  part  of  the  sac  below  the  ureter,  or  (4)  in  case  the  ure- 
ter is  placed  too  high,  cut  down  the  spur. 

(h)  When  the  ureter  is  strictured  at  the  level  of  its  entrance  into  the  pelvic 
pouch,  (5)  uretero-plastic  operations  should  be  performed  and  in  case  these 
do  not  appear  feasible,  (6)  a  lateral  or  (7)  an  end-to-end  anastomosis  between 
the  pelvic  pouch  and  ureter  should  be  made. 

(c)  When  the  ureteral  canal  is  obstructed,  a  lateral  or  end-to-end  anasto- 
mosis should  be  made. 

Technique  of  Operation. — The  patient  is  in  the  same  position  as  for  a 
neplirotomy,  that  is,  lying  on  the  healthy  side  with  the  loin  to  be  operated  upon 
exposed.  It  is  important  to  have  an  incision  sufficiently  long,  as  this  makes 
it  easier  to  work  on  the  renal  pelvis.  Besides  this,  it  is  important  always  to 
pass  a  ureteral  catheter  from 
below  up  to  the  renal  pelvis. 

(1)  Nephropexy. — For 
the  technique  of  this  opera- 
tion see  the  chapter  on 
Nephropexy.  The  replacing 
of  the  kidney  in  its  normal 
position  often  overcomes  the 
renal  retention  in  cases  of 
movable  kidney  and  estab- 
lishes a  satisfactory  empty- 
ing of  the  sac. 

(2)  Resection  of  the 
Pouch  {Operation  of  Alhar- 
ran). — The  technique  con- 
sists of  passing  a  ureteral 
catheter,  freeing  the  kidney 
from  its  external  capsule, 
making  an  incision  in  the 
renal  pocket  and  exploring 
the    cavity.      A     clamp     is 

then  applied  transversely  across  the  kidney  just  below  the  ureter,  and  another 
a  centimeter  below  it.  The  kidney  is  then  cut  through  between  the  two.  After 
this,  the  two  sides  of  the  kidney  pocket  are  united  by  interrupted  sutures  just 


Fig.  382. — Resection  of  Kidney  Pouch  below  the  Ureter. 
Two  clamps  are  placed  across  the  kidney  just  below  the  ureter 
and  the  organ  is  cut  through  between  them,  after  which  the 
two  sides  of  the  remaining  part  of  the  kidnej'  are  united. 


618 


OPERATIVE    SURGEKY   OF   THE    KIDNEY 


k'ltnv  the  rciuaiiiing  i-lainp  (Fig.  382).   A  ureteral  catheter  is  passed  through  the 
ureter  to  be  retained,  and  the  wound  closed,  leaving  in  a  lumbar  drain  down  to 

^  tlie  kidney.     The  kidney 

is  then  fastened  to  the 
abdominal  wall  by  fixa- 
tion sutures  in  such  a  way 
as  to  give  good  drainage  to 
the  organ  and  the  wound 
up  to  the  drain  is  closed. 
(3)  Capittonage  of  or 
"Reefing"  the  Dilatation 
below  the  Ureteral  Open- 
ing {Israel's  Operation). 
— The  object  is  to  bring 
the  ureteral  orifice  to  the 
lowest  point,  by  drawing 

Capittonage.  The  part  of  kidney  pouch  be- 
low the  ureter  is  drawn  up  by  a  series  of  tucks  or  reefs 
made  by  Lambert  sutures. 


up  the  low^er  part  of  the 
pocket  and  straightening  out 
the  ureter.  The  sutures  are  so 
placed  from  below  upward 
as  to  fold  in  the  walls  of  the 
dilated  pelvis  by  a  series  of 
tucks,  in  such  a  w^ay  as  to 
give  a  straight  course  to  the 
ureter.  Lembert  sutures  are 
used,  and  four  of  them  are 
passed  through  the  posterior 
wall  and  then  tied,  thus 
straightening  and  narrowing 
the  dilatation  (Fig.  383). 

In  certain  forms  of  dila- 
tation of  the  pelvis,  Albarran 
recommends  making  the  tuck 
in  the  pelvis  by  transverse 
rather  than  by  longitudinal 
sutures  (Fig.  384). 

(4)    Cutting  down  the  Ureteral  Spar  {Pijclo-uyeteral  Operation,  Trendelen- 
burg).— The  kidney  pocket  is  cut  through  at  a  point  opposite  the  ureter  to  its 


Fig.  384.- 


-Albarran's  Method  of  Suturing  in  Capit- 
tonage. 


EXPLORATIONS    AND    OPERATIONS 


619 


lowest,  cxfreiiiity   and   tlie   adjoin iiii;-   wall   of   tlic   ureter   is   cut   down    for   the 
same    distance.      A   long   nephrotomy    incision    is    made    tlirougli    the    kidney 


Fig.  385. — Cutting  Down  the  Ureteral  Spur. 
After  nephrotomy,  two  clamps  are  placed  in 
such  a  way  that  each  has  one  blade  in  the  ureter 
and  one  in  pelvis  pouch.  They  are  then  clamped 
and  the  combined  pelvic  and  ureteral  wall  is  cut 
through. 


to  the  pelvis,  which  is  opened  widely  to  the 
hottom  of  the  cavity.  Two  long-bladed  (Koch- 
er's)  forceps  are  then  introduced,  each  hav- 
ing one  blade  in  the  pelvis  of  the  kidney  and 
the  other  in  the  ureter.  A  ureteral  catheter 
is  passed  down  the  ureter.  A  knife  with  a 
thin  blade  is  then  used  to  cut  down  the  spur  to 
the  lowest  part  of  the  pelvic  pocket  (Fig. 
''>S,")).  The  walls  of  the  ureter  and  pelvis  are 
then  united  by  a  continuous  suture  on  both 
sides  (Fig.  386).  The  ureteral  catheter  is 
retained.  The  wound  is  then  closed  as  after 
any  nephrotomy.     It  is  a  difficult  operation. 

(5)  Uretero-pyeloplasty  (Fingers  Opera- 
lion). — The  ]ielvic  dilatation  is  due  to  the 
stricture  at  the  beginning  of  the   ureter    (Fig. 


Fig.  386. — Cutting  Down  the  Ureter.\l  Spur. 
Sutures  passed  uniting  pelvic  and  ureteral  Malls 
on  either  side. 


Fig.  387. — Uretero-pyelo- 
plasty.     The  longitudi- 
nal incision  through  the 
stricture  at  the   beginning  of  the 
ureter.     (After  Albarran.) 


620 


OPERATIVE    SURGERY   OF    THE    KIDNEY 


387).      This  operation   consists   in   dividing  the   stricture   by   a   longitudinal 
incision,    and    then    sewing    it    up    transversely.     Fig.    388    shows    how    the 

transverse  sutures   are   placed   and 
Fig.   389   shows  them  tied. 

(6)  Lateral  Anastomosis  of 
the  Pelvis  and  Ureter. — Cysto- 
scope  the  patient  and  catheterize 
the  ureter.  Perform  a  nephrot- 
omy. Approximate  the  lowest  end 
of  the  pelvis  w'ith  a  corresponding 
part  of  the  ureter  and  make  an  in- 
cision in  the  pelvis  at  this  point  and 
also  in  the  ureter  (Figs,  390  and 
391).  Bring  the  end  of  the  ure- 
teral catheter  through  the  open- 
ing in  the  ureter,  and  in  the  renal 


Fig.  388. 


Fig.  389. 


Fig.  388.  —  Uretero-pteloplasty.     Sutures  passed       pelvis     and     OUt     through     the     ue- 
so  as  to  leave  a  transverse  wound.     (Albarran.)  ,  ...  „,  , 

FIG.389.-URETERO-PYELOPLASTY.  Sutures  ligated,      phrotomy  mcision.      1  hen  sew  the 

making  the  strictured  part  of  the  ureter  the  widest       hack     part    of    the     iucision    in     the 

pelvis  to  the  back  part  of  that 
in  the  ureter.  Pass  a  fairly  large  fenestrated  catheter  over  the  smaller  one 
from  above  through  the  opening  in  the  kidney  and  pelvis  into  the  ureter. 
Then  sew  the  anterior  part  of  the  incisions  in  the  ureter  and  pelvis  together. 
Allow  the  fenestrated  cathe- 
ter to  remain  in  for  several 
days  until  a  communication 
of  large  size  has  been  made 
between  the  ureter  and  renal 
pelvis. 

(7)  End-to-end  Anasto- 
mosis of  Pelvis  and  Ureter 
{Trendelenburg' s  Operation^. 
— The  ureter  is  cut  through 
and  the  end  nearest  the  kid- 
ney ligated.  A  triangular  in- 
cision is  made  in  the  low- 
est part  of  the  pelvis  and 
the  split  end  of  the  lower 
segment  of  the  ureter  is 
sewed  in  it  by  catgut  and  re- 
inforced with  silk  (Fig.  392).  Albarran  does  a  nephrotomy  before  the 
anastomosis. 


FiG.  390.  '      /    /  Fig.  391. 

Fig.  390. — Lateral  Pelvic-ureteral  Anastomosis.  Show- 
ing the  nephrotomy  inci.sion  in  the  kidney  convexity,  the 
opening  in  the  lowest  part  of  the  pehac  pouch  and  in  the 
ureter  joining  it,  also  the  ureteral  catheter  in  situ.  (.\1- 
barran.) 

Fig.  391. — Lateral  Pelvic-ureteral  Anastomosis.  The 
wound  united. 


EXPLOEATIONS  AND  OPERATIONS 


621 


Drainage. — As  has  already  been  said,  it  is  important  to  always  cystoscope 
the  patient  and  catheterize  the  ureter  on  the  affected  side  before  beginning  the 
operation.  The  catheter  goes  through  the  ureter  into  the  pelvis  of  the  kidney. 
In  all  cases,  excepting  uretero-pyeloplasty,  this  should  be  done,  and  after  which 
a  catheter  of  large  size,  say  13  or  14  French  scale,  having  been  fenestrated, 
should  be  threaded  over  the  end  of  the  ureteral  catheter  in  the  loin  and  pushed 
with  it  through  the  operative  field  so  as  to  obtain  a  larger  anastomotic  opening 
for  drainage  between  the  renal  pelvis  and  the 
ureter.  The  incision  in  the  kidney  should  then 
be  closed  to  this  drain.      (See  Fig.  390.) 

A  catheter  25  to  30  French,  about  a  foot 
long,  is  then  inserted  into  the  wound  down  to 
the  kidney  and  tlie  abdominal  incision  is 
closed,  excepting  at  the  point  at  which  the 
drainage  tube  and  the  reno-ureteral  drain  comes 
through. 

While  the  lumbar  drain  is  in,  nearly  all  the 
urine  escapes  by  this  route.  It  is  well  to  irri- 
gate the  operative  field  twice  a  day  through  the 
ureteral  and  loin  catheters,  witb  boric  acid  if 
the  urine  is  clear,  or  with  a  1:  1,000  solution 
of  silver  if  it  is  turbid.  This  washes  away  ob- 
structions and  prevents  infection.  The  large 
kidney  drain  is  removed  on  the  third  day  in  hy- 
dronephrosis and  on  the  sixth  day  in  pyone- 
phrosis; the  catheter  in  the  pelvis  usually 
three  days  later. 

When  the  progress  is  not  satisfactory  in 
the  operative  field,  or  there  is  danger  of  a 
stricture  at  the  point  of  operation,  it  is  better 
to  leave  the  catheter  in  for  three  to  six  w-eeks. 
Sometimes  the  catheter  does  not  fit  well,  in  which  case  it  can  be  removed  and 
another  inserted.  In  making  this  change,  it  is  advisable  to  pass  a  mandrin 
into  the  catheter  already  in  place,  and,  after  having  removed  it,  to  keep  the 
mandrin  in  place  until  a  clean  catheter  has  been  passed  over  it  to  take  the 
place  of  the  one  removed. 

The  withdrawing  of  the  drain  is  sometimes  followed  by  pain  and  fever. 
When  a  catheter  has  been  left  in  the  ureter  that  is  not  satisfactory,  injections 
should  be  made  or  a  mandrin  passed.  If  no  catheter  has  been  passed  into  the 
ureter,  this  should  be  done,  which  will  often  reestablish  the  drainage  in  a  few 
days.  If  this  is  not  done,  it  will  be  necessary  to  again  open  the  lumbar  wound, 
thus  establishing  a  fistula.    A  few  weeks  later,  again  try  ureteral  catheterization. 


Fig.  392. — Kinked  Ureter  with  Ad- 
hesions Amputated  Below.  The 
lower  segment  is  partially  united  to 
an  opening  in  the  lowest  part  of  the 
pelvic  pouch.  Note  the  triangular 
shape  of  the  adjoining  cut  surfaces; 
a  wider  union  is  thus  obtained. 
(From  Albarran.) 


CHAPTER    XXXII 


THE   URETERS 


ANOMALIES    OF   THE   URETERS 


Owing  to  the  complexity  of  the  developmental  process,  anomalies  of  the 
ureter  are  manifold.  They  may  be  classified  into :  Anomalies  in  numLer — a 
deficiency  or  an  excess  of  ureter,  anomalies  in  position,  anomalies  in  caliber. 

1.  Anomalies  in  Number. — Deficient  Uretek. — These  are  rare.  The 
ureter  and  the  kidney  may  both  be  absent,  or  the  hilum  alone  is  missing,  the 

ureter    coming    directly    from    the    an- 
terior and  lower  part  of  the  kidney. 

An  excess  of  ureter  is  much  more 
frequent.  Supernumerary  ureters  are 
found  in  three  per  cent  of  cases,  accord- 
ing to  Poirier.  The  supernumerary 
ureter  may  be  bilateral,  but  it  is  more 
frequently  unilateral.  The  double  ure- 
ter may  be  complete,  or  it  may  affect  only 
the  upper  portion  of  the  canal.  The 
supernumerary  ureter  is  always  placed 
above  the  normal  one,  and  drains  the 
upper  part  of  the  kidney. 

Fig.  393  is  in  a  single  (unsymmet- 
rical)  kidney  (Pousson's  case).  The 
ureters  empty  into  the  regular  angles  of 
the  trigone.  If  it  had  been  displaced 
down,  it  would  probably  have  Ik'cu  a 
horseshoe  kidney. 

Supernumerary  ureters  have  some 
surgical  interest.  If  not  strictured,  or 
not  ending  abnormally,  they  do  not  cause 
any  symptoms ;  but  they  are  frequentW  strictured,  causing  partial  hydro- 
nephrosis, or  they  may  have  abnormal  endings.  The  portion  of  kidney  drained 
by  a  supernumerary  ureter  may  be  infected  alone,  the  other  part  being  healthy. 
For  this  reason  it  is  necessary  to  detect  them,  which  has  been  done  on  the  living 
by  cystoscopy,  ureteral  catheterization  and  radiography.  Cases  have  been  seen 
622 


Fig.  393. — Two  Ureters  Each  Emptying  into 
THE  Normal  Orifices  at  Either  End  of  the 
Trigone,  Coming  from  a  Single  Unsym- 
metrical  Kidney  on  the  Right  Side.  (Pous- 
son's case.) 


ANOMALIES    OF   THE   URETERS 


623 


of  partial  gonorrheal  pyelitis,  of  ])artial  pyoneplirosis,  of  piii'iial  liil)ci-ciilosis, 
although  very  rare.  Fig.  394  shows  u  doiiljle  ureter  on  the  Jcft  side,  as  seen  hy 
radiography  after  ureteral  catheterization. 


LEFT 
SIDE 


RIGHT 
SIDE 


\\^         .JNNER'lLEFT 

"    URETER  OPENING 


OUTER  le:ft 


URETER  OPENING    '^ 


\i  / 


RIGHT  URETER 
OPENING 


Fig.  394. — A  Double  Ukkter  Coming  from  the  Left  Kidney,  as  Seen  by  Kauiogr.\pht. 

(Bransford  Lewis's  case.) 

2.  Anomalies  in  Position. — In  transposition  at  the  hilum,  the  ureter 
is  found  lying  in  front  of  the  renal  artery. 

Abnoemal  Endings. — The  most  frequent  of  the  latter  are  in  the  prostatic 
utricle  in  men  and  in  the  anterior  vaginal  fornix  in  women.     They  have  been 


G24 


TTTT-:    rUETERS 


seen  also  in  the  seminal  duets  and  vesicles,  in  the  roctnm  and  in  the  Fallopian 
tubes.  An  eudin<>-  in  the  urethra  (n-  in  the  vai^ina  liives  rise  to  a  special  variety 
of  incontinence,  tlie  ])i-()per  treatment  of  which  is  imphintarinn  (if  the  abnormal 
nreter  into  the  bhidder. 


Fig.  395. — Vesical  Ends  of  the  Ureters  Prolapsing  into  Bladder.     (After  Knorr.) 


Intravesical  prolapse  of  the  lower  end  of  the  ureter  may  be  congenital, 
but  it  is  also  acquired  in  some  cases.     It  varies  in  extent  from  slight  bulging 

into  the  bladder  to  a  large  projecting  mass. 
It  is  caused  by  a  lack  of  support  in  the  mus- 
cular tissues  of  the  bladder  wall  and  favored 
by  too  direct  an  entrance  of  the  duct  into  this 
organ.  The  result  is  a  stenosis  of  the  orifice 
of  the  ureter  with  all  the  ordinary  conse- 
quences. Fig.  395  shows  the  ends  of  the 
ureters  prolapsing  into  the  bladder. 

The  treatment  for  this  condition  does  not 
offer  much  hope  of  improvement,  if  any.  It 
consists  of  either  shortening  the  ureter  or 
uretero-cystostomy. 

A  Diverticulum  of  the  Exd  Ureter 

IX  THE  Bladder  Wall. — Fig.  396  shows  an 

abnormal  ureteral  ending  in  a  case  of  double 

sclerotic  kidney  in  a  girl  sixteen  years  of  age. 

The  kidneys  were  two  inches  in  leng-th.     On 

the  left  side  was  a  spleen  with  a  round  border 

and  narrow  in  its  transverse  diameter  in  which 

_     „„„      .  ^  ^  no  notch  could  be  felt.     The  girl  had  a  slight 

r  iG.  396. — A  Diverticulum  of  the  Part  _  \  . 

OF  THE  Ureter  Passing  THROUGH  THE     polyuria  and  the  case  was  diagnosticated  as 

Bladder  Wall,  Preventing  Cathe-  f        i  i      •         n    j^i       i   jj^  i  •  i  r\ 

TERizATioN.    (Author's  case.)  One  of  tuberculosis  ol  the  lett  kidney.     Un 


INJURIES    OF    THE    URETERS  625 

cystoscopy,  two  iivcteral  openings  were  seen,  but  several  attempts  to  catlieterizo 
the  right  ureter  proved  a  failure,  as  the  catheter  only  entered  the  ureteral 
mouth.  There  was  no  urinary  swirl  coming  from  that  side  and  we  were  not 
sure  that  urine  escaped  or  that  the  kidney  was  present.  A  number  of  consultants 
considered  the  case  one  of  a  probable  tubercular  kidney  on  the  left  side  with  a 
possible  absent  kidney  on  the  right,  and  advised  an  exploratory  incision  on  the 
riglit  side  to  be  followed  perhaps  by  a  left  nephrectomy,  but  the  patient  died  of 
uru'uiia  before  the  consent  of  the  family  could  l)e  obtained.  Autopsy  showed  a 
sacculatiou  of  the  lower  end  of  the  right  ureter. 

3.  Anomalies  in  the  Caliber. — Anomalies  in  the  caliber  of  the  ureter  are 
the  most  numerous  of  all  and  have  been  studied  in  the  chapter  on  Hydro- 
nephrosis. The  irregularity  in  caliber  may  be  due  to  compression  of  the  duct 
by  an  abnormal  vessel.  The  principal  causes  of  irregularity  of  caliber  are  in 
the  wall  itself:  Stricture,  congenital  valves  and  the  persistency  of  the  fetal 
condition. 

INJURIES    OF   THE   URETERS 

Accidental  Wounds 

Etiology. — Accidental  wounds  of  one  or  both  ureters  are  of  exceptional 
occurrence.  They  may  be  the  result  of  knife  thrusts,  of  wounds  from  any 
sharp-pointed  weapon,  instrument  or  tool,  or  of  gunshot  injuries.  The  injuries 
are  usually  found  in  the  immediate  vicinity  of  the  renal  pelvis. 

The  symptoms,  diagnosis  and  treatment  of  these  rare  cases  are  practically 
the  same  as  those  of  wounds  of  the  pelvis  of  the  kidney.  The  differential  diag- 
nosis between  injuries  of  the  renal  j)elvis  and  the  upper  segment  of  the  ureter 
is,  indeed,  clinically  impossible  without  an  exploratory  incision. 

The  prognosis  of  accidental  wounds  of  the  ureter  depends  largely  upon  the 
timeliness  of  diagnosis  and  of  operative  treatment.  When  they  are  left  to  them- 
selves, the  prognosis  of  these  wounds  is  extremely  unfavorable,  death  or  per- 
manent fistula  being  a  frequent  outcome  as,  owdng  to  the  small  size  of  the  canal, 
its  injur}^  is  frequently  accompanied  by  fatal  lesions  of  adjacent  parts  or 
organs.  Penetration  of  the  peritoneum  often  terminates  in  peritonitis  and 
death.  Localized  lesions  of  the  duct  are  followed  by  the  establishment  of  per- 
manent fistulic,  imless  operated  upon,  or  else  the  kidney  on  the  aifected  side 
becomes  obliterated.  In  the  j^resence  of  sepsis  or  suppuration  complicating 
such  wounds,  we  may  expect  to  see  the  obstruction  of  the  proxinuil  ureteral 
end ;  or  the  development  of  uretero-pyelo-nephritis,  with  its  sequels  of  renal 
atrophy ;  or  pronounced  septicemia  if  there  is  retention  of  infected  urine  in  the 
tissues;  or  a  permanent  fistula. 

Less  formidable  wounds  of  the  ureter,  such  as  punctures,  oblique  divisions 
or   clean-cut   longitudinal    incisions,    are   very    infrequent.      The   prognosis    of 


L 


626  THE   URETERS 

operated  cases,  especially  those  attended  It*  early,  is,  of  course,  imicli  better, 
even  when  the  wound  is  serious. 

Treatment. — The  treatment  of  accidental  wonnds  of  the  ureters  nuiy  be 
summed  up  as  follows : 

If  the  peritoneum  has  been  injured,  ojjen  the  peritoneal  cavity  and  examine 
its  contents  for  other  injuries  which  should  be  repaired  as  indicated,  [f  a 
local  collection  of  pus  or  urine  is  present,  sponge  it  dry,  then  sponge  it  with 
salt  solution  and  afterwards  with  peroxid  of  hydrogen.  If  the  ureter  can  be 
more  easily  operated  on  through  the  abdominal  incision,  perform  the  operation 
of  nreterorrhaphy,  uretero-ureterostomy,  nretero-cystostomy,  if  in  the  lower 
part  of  the  ureter.  Then  make  extraperitoneal  drainage  and  close  the  peri- 
toneum over  the  seat  of  operation.  Intraperitoneal  drainage  down  to  the  seat 
of  injury  may  also-  be  nsed,  especially  if  there  has  been  pus  in  the  wound  or 
urine. 

In  case  the  wound  is  in  the  npper  segment  of  the  ureter  where  a  loin  in- 
cision would  better  expose  the  nreter,  it  is  advisable  to  treat  and  close  the 
peritoneal  wound  as  already  indicated  and  then  to  open  the  loin  and  do  the 
ureteral  operating  through  the  lumbar  incision. 

If  after  opening  the  peritoneal  cavity  it  is  found  that  the  peritoneum  and 
the  contents  of  its  cavity  are  not  involved,  no  intraperitoneal  drainage  is  re- 
quired and  the  M^ound  can  be  closed  and  all  the  work  done  by  the  extraperitoneal 
route,  drainage  being  kept  up  through  the  outer  incision  until  urinary  leakage 
has  ceased. 

In  any  case,  wherever  the  operation  is  performed,  a  ureteral  catheter  should 
be  passed  by  cystoscopy  up  and  through  the  injured  portion  of  the  ureter  be- 
fore the  operative  work  is  begun,  and  it  should  be  retained  afterwards  for 
draining  the  urine  from  the  kidney  past  the  seat  of  the  ureteral  operation. 

Operative  Injuries 

Operative  injuries  of  the  ureters  are  quite  common  and  should  be  repaired 
as  indicated  at  the  time  of  the  accident. 

Accidental  injuries  usually  occur  in:  Operations  on  the  female  generative 
organs  such  as  fibromyotomy,  salpingectomy,  salpingo-oophorectomy,  oophorec- 
tomy, vaginal  or  abdominal  hysterectomy,  operations  during  labor  and  use  of 
forceps ;  operations  on  the  rectum  or  sigmoid. 

Symptoms. — The  symptoms  of  operative  wounds  of  the  ureter  are  apt  to 
be  obscure  and  indefinite,  until  the  escape  of  urine  becomes  manifest  either  in 
the  vagina,  or  in  the  peritoneal  cavity.  Leakage  into  the  peritoneal  cavity  is 
followed  by  a  train  of  symptoms  varying  according  to  the  normal  or  septic  con- 
dition of  the  urine.  Acute  general  peritonitis  may  arise  in  either  case ;  but  it 
will  surely  follow  infection  with  septic  urine,  in  which  case  the  symptoms  of 


I 


INJURIES    OF   THE   URETERS  627 

general  peritonitis  will  be  present.  Normal  iii-iiic,  under  favorable  eonditions, 
may  be  tolerated  l)j  the  general  ])(>ritoneal  cavity,  becoming  partially  absorbed, 
or  occasionally  draining  through  the  abdominal  incision. 

Localized  peritonitis,  subacute  or  chronic,  may  develop  as  the  result  of  the 
accumulation  of  urine  in  a  definite  area  of  the  peritoneal  cavity,  especially  when 
susee])tibility  to  infection  is  increased  by  the  ])resence  of  adjacent  raw  surfaces 
or  of  loose  adhesions.  The  usual  outcome  of  this  localized  inflammatory  process 
is  abscess  formation,  circumscribed  in  character  and  ending  in  the  discharge  of 
pus  and  urine  and  the  establishment  of  a  septic  urinary  fistula  at  the  site  of  the 
spontaneous  or  artificial  rupture  of  the  abscess. 

Diagnosis. — The  diagnosis  of  operative  injuries  of  the  ureter  is  usually 
easy,  on  account  of  the  direct  ocular  evidence  of  the  accident.  When  its  occur- 
rence has  not  come  at  once  to  the  operator's  attention,  when  the  ureter  has  been 
ligatured  by  mistake  in  place  of  or  together  with  the  uterine  artery,  or  has 
become  occluded  by  the  compression  of  ligatured  adjacent  tissues,  the  diagnosis 
is  not  so  easy.  In  the  first  instance,  no  discharge  of  urine  through  the  vagina 
is  noted  until  an  abscess  has  formed,  or  it  has  ruptured,  or  until  the  sloughs 
have  begun  to  separate  and  a  fistula  has  formed ;  whereas  in  the  second  instance, 
an  occluded  ureter  would  give  rise  to  renal  pain  and  ureteral  catheters  would 
find  the  obstruction.  Both  nreters  have  been  completely  divided  during  the 
performance  of  major  abdominal  operations,  without  giving  rise  to  any  imme- 
diate symptoms. 

Prognosis. — The  prognosis  of  operative  injuries  of  the  ureter  is  favorable 
both  as  to  the  prolongation  of  life,  and  also  as  to  the  preservation  of  the  kidney, 
provided  the  injury  is  at  once  detected  and  properly  repaired.  Complete 
division  of  the  ureter  has  been  treated  successfully  by  prompt  nreteral  anasto- 
mosis by  one  of  the  methods  described  farther  on.  Incomplete  division  of  the 
ureter  naturally  offers  even  more  encouraging  prospects  as  to  the  preservation 
of  the  ureteral  lumen  and  functions,  provided  prompt  repairs  be  made.  The 
prognosis  is,  of  course,  far  more  grave  when  septic  peritonitis  has  set  in,  or 
when  an  acute  infection  has  developed  in  the  kidney.  In  such  cases,  an  imme- 
diate operation  is  called  for. 

Treatment. — The  management  of  ureteral  injuries  varies  according  to  ex- 
tent and  direction  of  the  lesion.  The  wound  may  be  incomplete,  with  a  longi- 
tudinal, transverse  or  oblique  tear  of  the  duct,  or  the  ureter  may  be  completely 
severed. 

In  incomplete  longitudinal  wounds  of  the  ureter,  spontaneous  repair  of  the 
lesions  may  take  place  after  establishing  thorough  drainage.  It  is  advisable, 
however,  to  suture  the  ureter  if  accessible,  after  passing  a  ureteral  catheter 
through  the  injured  area  from  the  bladder.  Interrupted  sutures  of  fine  chromic 
gut  are  preferred.  1  do  not  believe  in  the  Lembert  method,  as  I  fear  it  may 
cause  stricture.     Many  prefer  not  to  use  sutures. 


628  THE    ITRETERS 

In  uniting  very  short  transverse  wounds,  where  one  third  of  the  circum- 
ference of  the  duct^  or  less,  is  included  in  the  lesion,  ureterorrhaphy  is  per- 
formed. Instead  of  a  stricture  forming,  the  ureter  will  then  present  a  dilata- 
ti(.)n  at  the  k'vcl  of  the  wound. 

When  the  duct  is  completely  severed,  uretero-ureterostomy,  uretero- 
cystostomy,  or  uretero-pelvic  anastomosis  should  he  performed  according  to 
the  position  of  the  injury,  whether  it  he  near  the  middle,  upper  or  lower  end 
of  the  ureter.  AVhen  the  continuity  of  the  ureter  is  destroyed,  it  is  essential 
to  determine  the  presence  or  absence  of  an  extensive  loss  of  substance.  Even  when 
the  two  ends  are  rather  widely  separated,  they  can  often  be  approximated.  In 
virtue  of  its  elasticity,  the  ureter  can  actually  be  stretched  to  an  average  extent 
of  about  8  cm.  for  the  entire  canal  without  diminishing  its  caliber  or  interfer- 
ing with  its  functional  activit3^ 

In  performing  an  end-to-end  anastomosis,  uretero-ureterostomy,  the  Poggi 
operation  is  the  one  of  choice.  In  this  case  the  ureteral  ends  should  be  cut  oif 
squarely  before  uniting  the  two  segments. 

When  the  wound  in  the  ureter  is  partial  and  oblique  with  fairly  even 
edges  it  can  be  united  by  suture  or  can  be  allowed  to  heal  without  suture ; 
but  in  either  case  with  a  retained  catheter  in  the  ureter.  It  is  in  the 
cases  of  the  oblique  wounds  in  Avhich  an  end-to-end  anastomosis  is  to 
be  performed  that  Bovee's  operation  may  be  of  great  service,  as  the  unin- 
jured side  of  the  ureter  can  be  cut  through  in  a  line  corresponding  to  the 
oblique  line  of  the  wound  and  then  the  Bovee  anastomosis  made.  All  these 
methods  are  explained  in  the  cha23ter  on  the  Operative  Surgery  of  the 
Ureter, 

Contraindications  to  the  suturing  of  ureteral  wounds  are  general  weakness 
of  the  patient,  long  duration  of  the  operation  in  case  of  an  operative  trau- 
matism, and  very  severe  urinary  infection.  In  these  cases,  temporary  external 
drainage  down  to  the  seat  of  injury,  together  with  a  retained  ureteral  catheter, 
may  be  resorted  to  in  case  the  injury  is  incomplete. 

INFLAMMATION    OF   THE   URETER 

Etiology. — Inflammation  of  the  ureter  may  be  primary  or  secondary.  Pri- 
mary ureteritis  is  very  rare.  It  may  develoj)  after  an  injury  to  the  ureter,  or 
about  a  stone  impacted  in  the  duct. 

Secondary  ureteritis  may  result  from  an  extension  by  contiguity  from  a 
neighboring  inflamed  organ,  or  by  continuity  from  some  other  part  of  the 
urinary  tract.  When  it  results  from  an  extension  by  contiguity  in  men,  it 
usually  complicates  a  pelvic  adenitis  or  proctitis.  Such  cases  are  very  rare  and 
the  inflammation  is  more  marked  as  a  periureteritis  than  as  a  simple  ureteritis. 
In  women,  the  extension  by  contiguity  is  more  common,  on  account  of  the  in- 


INFLAMMATION    OF    THE    URETER 


629 


tiiiiate  relations  between  the  lower  part  of  the  nreter  and  the  internal  female 
genitals,  and  ureteritis  has  been  found  secondary  to  septic  metritis  due  to  child- 
birth and  other  causes,  to  a  salpingitis,  pelvic  cellulitis,  infected  hematoma 
and  cancer  of  the  uterus. 

Secondary  ureteritis  is,however,usually  the  result  of  an  extension  by  continu- 
ity,either  down  frt)m  the  kidney  or  u]i  fi-oni  the  bladder.  It  is  accordingly  s])oken 
of  as  ascending  or  descending,  and 
it  is  still  a  question  which  of  the 
two  is  the  more  frequent.  Descend- 
ing ureteritis  is  secondary  to  pye- 
litis, pyelo-nephritis,  or  pyoneph- 
rosis, which  are  due  to  obstruction, 
renal  calculus,  tuberculosis  or  tu- 
mor. The  ascending  ureteritis  fol- 
lows a  chronic  cystitis  associated 
with  obstruction,  such  as  vesical 
calculus  or  tumor ;  hypertrophy, 
cancer  or  stone  of  the  prostate ;  or 
stricture  of  the  urethra  of  congeni- 
tal, gonorrheal  or  traumatic  ori- 
gin.    (See  Fig.  397.) 

Secondary  ureteritis  may  also 
be  due  to  a  partial  or  complete 
paralysis  of  the  bladder,  due  to  in- 
juries or  sclerosis  or  tumors  of  the 
spinal  cord,  which  give  rise  to 
retention  of  urine,  cystitis  and 
pyelitis. 

Pathology. — In  cases  of  acute  ureteritis,  the  ureter  shows  a  swollen  mucosa 
and  narrowing  of  the  lumen.     This  stage  is  rarely  seen. 

In  chronic  ureteritis,  two  varieties  of  ureters  are  seen.  In  the  cases  in 
which  obstruction  is  the  predominating  feature,  especially  if  situated  low 
down  in  the  canal  and  the  ureter  has  had  a  chance  to  dilate  before  infec- 
tion has  taken  place,  the  canal  is  a  dilated,  elongated,  thin-walled  and  sac- 
culated tube.  The  kinks  between  the  sacculations  are  held  by  adhesions 
so  that  the  latter  are  permanent.  On  the  other  hand,  when  the  infec- 
tion has  taken  place  before  the  walls  have  had  a  chance  to  dilate,  the 
ureter  is  a  thick,  rigid  tube  with  occasional  strictures  due  to  inflammatory 
thickening. 

It  is  remarkable  what  a  degree  of  dilatation  can  take  place  in  a  short  time 
in  cases  in  which  there  is  back  pressure  of  urine,  when  the  infection  of  the 
ureters  has  set  in  quickly.      Fig.   398  shows  the  ureter  of  a  patient  on  my 


Fig.  397.  —  Ureteritis  and  Associated  Pyoneph- 
rosis. Showing  the  irregular  dilated  condition  of 
the  ureter  and  the  dUated  condition  of  the  pelvis. 
(From  Pousson.) 


630 


THE   URETERS 


.service  at  the  Cohinibiis  Hospital  who  fractiirerl  his  spine  one  month  before 
death.     The  iirclcvs  aw.  larao,  snceiihited  ;nul   inflamed,  while  his  kidneys  are 

in   a   quite   advanced   state 
of   pyonephrosis. 

Strictures  of  the  nretcr 
are  most  connnonly  found 
ill  tlic  parts  of  the  canal 
wliich  are  naturally  the  nar- 
rowest. The  lesions  of  the 
iiiiicous  membrane  resendjle 
tlioso  of  chronic  cystitis, 
besides  which  there  are  two 
peculiar  conditions  that  are 
occasionally  observed,  nu- 
merous small  cysts  and 
leukoplakia. 

Symptoms. — As  ureter- 
itis is  generally  simply  an 
extension  of  an  inflamma- 
tion from  some  other  or- 
gan, it  possesses  almost  no 
characteristic  symptoms,  ex- 
cepting perhaps  jiain  re- 
sembling a  renal  colic. 
Pain  is  always  a  symjjtom 
of  ureteral  obstruction. 
Abdominal  palpation  -will 
sometimes  detect  an  indu- 
rated or  dilated  duct.  In- 
flamed ureters  are  also  often 
felt  by  rectum  or  vagina. 
Pyuria  is  present,  but  it  is  difficult  to  differentiate  the  pus  coming  from  the 
ureter  from  that  coming  from  the  renal  pelvis.  Cystoscopy  may  show  the 
mouths  of  the  ureter  to  be  red  and  swollen,  or  dilated. 

Treatment. — Preventive  treatment  consists  in  treating  the  l:)laddcr  wlicn 
it  is  inflamed.  After  the  diagnosis  has  been  made,  the  important  part  of  the 
treatment  is  to  remove  the  causative  factor  of  obstruction  by  operations,  such 
as  urethrotomy,  cystotomy  and  prostatectomy.  If  the  kidneys  are  much  in- 
volved, they  should  be  treated  by  the  method  already  outlined  in  the  chapter 
on  Suppurative  Diseases  of  the  Kidney.  Irrigations  of  the  ureters  by  the  ure- 
teral catheter  can  be  made  with  solutions  of  silver  nitrate  from  1 :  8,000  to 
1 :  1,000,  or  injections  through  the  catheter  of  a  small  amount  of  -J  to  1  per 


Fig.  398.  —  Dilation  of  the  Renal  Pelvis  and  Ureter  in 
A  Case  of  Acute  Ureteritis  of  One  Month's  Dura- 
tion IN  A  Patient  Dying  One  Month  after  a  Fracture 
of  the  Spine.     Autopsy  specimen.     (Author's  case.) 


TUMORS    AND    CYSTS    OF    THE    URP:TER 


631 


cent  of  protargol,  or  argjrol  10  per  cent.     Urotropin,  salol,  Ijenzoatc  of  soda 
are  recommended  as  internal  urinary  antiseptics. 

TUMORS   AND    CYSTS    OF   THE   URETER 


Tumors 

Etiology. — These  new  growtlis  arc  very 
rare,  but  wlien  they  occur  it  is  always  after 
thirty  years  of  age.  Ureteral  calculus  may 
he  the  cause,  as  a  calculus  of  long  standing 
may  cause  sufficient  irritation  and  hardening 
of  the  tissues  to  predispose  to  malignancy. 

Pathology. — Both  the  connective  tissue 
and  embryonic  form  of  tumor  have  been 
found  as  primary  or  secondary  growths  in 
the  ureters.  Of  the  former  class  are  papil- 
lomas and  epitheliomas  (Fig.  399).  Of  the 
second  class  are  sarcomas,  myxomas  and 
rhabdomyxomas. 

In  case  these  growths  are  not  primary, 
they  are  secondary  by  extension  from  the 
kidney,  bladder  or  adjacent  tissues.  I  have 
never  to  my  knowledge  had  a  case  of  primary 
tumor  of  the  ureter,  although  I  have  had 
tumors  of  the   bladder,   that  have   involved 


* 


\ 


Fig.  400. — Cervix  with  a  Cancerous  Growth  That  Has  Involved 

THE  Ureter  and  Bladder  (C)  .  U  and  B  show  the  uterus  and  bladder 
covered  by  peritoneum ;  Ur.  shows  the  ureter  outside  the  peritoneum 
passing  by  the  cervix  in  its  route  to  the  bladder.     (Author's  case.) 


632  THE   URETEES 

and  occluded  the  ureter,  and  cancer  of  the  cervix  uteri,  that  has  also  involved  it 
(Fig'.  400,  author's  case). 

Symptoms. — The  principal  syniptonis  are  hematuria,  swelling  and  pain, 
the  same  as  in  tiunor  of  the  kidney.  Hematuria  is  usually  the  first  symptom 
and  may  not  be  associated  with  ])ain.  It  generally  comes  on  without  cause,  is 
profuse  and  thoroughly  mixed  with  the  urine. 

The  swelling  can  sooner  or  later  be  detected  and  may  lead  to  renal  reten- 
tion, in  which  ease  the  kidney  can  often  be  outlined  as  w'ell.  Pain  may  be 
present  as  a  dull  ache  or  it  may  be  of  a  colicky  nature. 

Examination. — Examination  of  the  urine  may  show  red  blood  cells,  ure- 
teral epithelia,  atypical  cells  and  tumor  fraginents.  Later,  if  infection  takes 
place,  pus  will  also  be  present. 

Examination  of  the  bladder  may  show  tufts  of  the  gTOwth  springing  out 
of  the  ureter.  Ureteral  catheterization  will  show  an  impediment  in  the  ureter. 
Recto-abdominal  palpation  may  disclose  the  growtli  if  it  is  at  the  lower  end  of 
the  ureter,  while  abdominal  palpation  may  reveal  it  when  situated  in  the  upper 
part  of  the  canal. 

After  infection  takes  place,  pyelo-nephritis  or  pyonephrosis  will  develop 
and  there  will  be  an  elevation  of  temperature,  besides  which  the  kidney  can 
probably  be  found  enlarged  on  palpation.  Palpation  of  the  adjacent  organs  will 
also  give  us  some  clew  to  a  secondary  involvement  from  the  uterus  or  gut. 

Prognosis. — The  prognosis  is  bad,  as  a  pyelitis  resulting  in  a  pyonephrosis 
will  destroy  the  adjoining  kidney  tissue. 

Treatment. — Xephrectomy  and  total  ureterectomy.  When  the  gTowth  in- 
volves a  segment  of  the  bladder  about  the  ureter,  that  part  of  the  ureter  and 
also  the  adjoining  part  of  the  bladder  wall  should  be  removed. 

Cysts  of  the  Ueeters 

Etiology. — Cystic  growths  are  usually  found  in  the  lower  part  of  the  duct. 
They  are  supposed  to  develop  either  from  enlarged  mucous  glands  or  the  epi- 
thelial spaces  of  Brunn,  or  else  to  be  caused  by  parasites.  The  cause  is,  there- 
fore, not  yet  determined.  They  are  most  probably  caused  by  parasites,  as  pso- 
rosperms  due  to  coccidia  have  been  found  in  both  the  ureter  and  the  renal 
pelvis.  Small  hydatid  cysts  are  sometimes  caught  and  retained  in  the  ureter 
in  cases  in  which  a  hydatid  cyst  of  the  kidney  has  broken  into  the  renal  pelvis. 
The  most  interesting  case  of  chronic  cysts  of  the  ureters  that  I  have  known  was 
one  of  Bond  Stow's,  in  w^hich  not  only  were  chronic  ureteral  cysts  present  in  the 
ureters,  but  the  patient  had  double  ureters  on  both  sides,  all  of  which  con- 
tained cysts. 

Pathology. — The  interior  of  the  ureter  is  usually  in  a  state  of  catarrhal 
ureteritis  and  appears  studded  with  minute  vesicles  the  size  of  a  pea,  of  a 
yellow-brown  color,  which  contain  a  transparent  fluid. 


FOEEIGN  BODIES  IN  THE  URETER:  URETERAL  CALCULI  633 

Symptoms. — These  cysts  may  give  rise  to  no  symptoms  or  there  may  be 
some  paiu  or  hematuria. 


FOREIGN   BODIES   IN   THE   URETER:   URETERAL   CALCULI 

Etiology. — A  stone  may  form  primarily  in  the  ureter,  but  such  primary 
ureteral  calculi  are  very  rare.  They  are  generally  small  and  of  a  phosphatic 
comiDOsition.  Xearly  all  ureteral  stones  are  secondary,  that  is,  they  are  formed 
in  the  kidney  and  while  descending  along  the  ureter  have  become  impacted  at 
some  point,  usually  one  of  the  narrow  parts  of  the  passage. 

The  etiology  of  ureteral  stones  is,  therefore,  that  of  renal  calculi ;  but  we 
have  to  mention  here  the  factors  favoring  impaction  which  are  the  size,  the 
irregular  outline  and  the  rough  surface  of  stones.  These  set  up  a  continuous 
irritation  of  the  ureteral  wall,  followed  by  spasm ;  later  inflammatory  changes 
of  the  wall,  until  at  last  ulcerations  and  cicatricial  strictures  are  produced,  all 
of  which  contribute  to  make  the  impaction  tighter  and  more  permanent. 
Previous  attacks  of  ureteri- 
tis and  kinks  of  the  canal  \ 
also  favor  impaction.  ' 

Once  impacted,  the  stone 
grows  by  the  deposit  of  ad- 
ditional layers  and  usually 
assumes  an  oblong  shape. 
The  above-mentioned  lesions 
of  the  wall  may  go  on  to 
pressure  atrophy,  to  per- 
forations with  periureteral 
abscess  and  urinary  infil- 
tration, although  abscess 
formation  and  urinary  ex- 
travasation are  exceedingly 
rare. 

While  impaction  may 
occur  at  any  point  in  the 
duct,  the  accident  is  more 
common  at  its  narrowest 
parts,  which  are  either  im- 
mediately below  the  renal 
pelvis,  just  above  the  en- 
trance into  the  bladder  or  in  the  middle  third  of  the  duct.  In  the  lower 
portion  of  the  duct,  a  calculus  may  be  arrested  near  the  ischium,  near  the  outer 
bladder  wall,  in  the  part  passing  through  the  bladder  wall ;  or  a  calculus  may 


Fig.  401. — Positions  of 
Ureter.\l  Calculi 
That  the  Author 
Has    Encountered. 


634  THE   URETERS 

be  in  the  vesical  portion  of  the  ureter,  protruding  into  the  bladder  cavity.  Fig. 
401  shows  the  position  of  stones  that  I  have  encountered  in  practice. 

Character  of  Calculi. — Calculi  met  with  in  the  ureter  vary  considerably  as 
to  form,  composition,  size  and  nuudjer.  They  are  usually  no  larger  than  a 
cherry  pit,  but  the}'  have  been  met  with  as  large  as  a  hen's  egg.  Their  compo- 
sition resembles  that  of  renal  and  vesical  calculus  (uric  acid,  urates,  phosphates 
and  calcium  oxalates),  their  consistency  varying  with  their  chemical  character. 
They  are  usually  single,  but  may  be  multiple  with  facets  adjusted  to  each 
other.  Civiale  observed  seven  stones  arranged  in  this  fashion  and  Cru- 
veilhier  mentions  a  series  forming  a  long  chain  from  the  renal  pelvis  to  the 
bladder. 

Symptoms.— All  ureteral  calculi  do  not  always  present  the  same  clinical 
symptoms.  They  may  be  of  the  transient  variety,  passing  through  the  canal 
in  from  a  few  hours  to  a  few  days,  accompanied  by  colicky  pains  and  often 
hematuria;  the  complete  obstructive  type  giring  rise  to  anuria  in  certain  con- 
ditions, aud  latent  calculi  that  remain  in  the  ureter  for  a  long  time  and  permit 
the  passage  of  urine  by  their  sides.  In  some  cases,  there  are  no  symptoms  of 
ureteral  calculi,  whereas  in  other  cases  they  are  most  alarming.  We  can  dis- 
miss the  consideration  of  transient  calculi  in  a  few  words  by  saying  that  they 
are  simply  small  renal  calculi  passing  through  the  ureter ;  that  their  symptoms 
are  then  those  of  renal  calculi  and  are  considered  in  that  chapter. 

AYe  will  now  pass  to  the  consideration  of  latent  ureteral  calculi  and  reserve 
that  of  the  complete  obstructive  calculi  causing  anuria  for  the  last,  as  it  is  the 
most  important. 

Latent  ureteeal  calctli  are  not  always  small  concretions,  as  one  of  the 
largest  calculi  in  Israel's  records  measured  seven  inches  in  length  and  two  and 
one  half  in  circumference  and  had  given  rise  to  but  few  symptoms.  In  latent 
cases,  the  ureter  is  only  partially  occluded  and  consequently  some  urine  leaks  be- 
tween the  stone  and  the  ureteral  walls.  If  these  cases  are  not  relieved  surgical- 
ly, the  obstruction  is  sufficient  to  give  rise  to  uronephrosis  and  later  to  pyo- 
nephrosis, if  infection  takes  place,  as  it  usually  does.  There  may  be  slight  pain 
along  the  course  of  the  ureter  in  these  cases  and  a  history  of  renal  colics  and  of 
calculi  having  been  passed,  but  no  other  symptoms.  The  course  of  chronic  cases 
of  ureteral  stone  is  generally  long  and  may  cover  a  number  of  years. 

Diagnosis. — The  diagnosis  of  ureteral  calculi  in  latent  cases  is  always  dif- 
ficult and  depends  upon  a  thorough  examination  of  the  patient.  It  was  still 
more  difficult  before  radiography  was  introduced.  ]^ow,  when  we  are  suspicious 
of  a  ureteral  calculus,  the  patient  is  radiographed  and  the  shadows  of  calculi 
looked  for.  It  is  sometimes  difficult  to  interpret  the  findings,  first,  because 
certain  ureteral  calculi  on  account  of  their  composition  do  not  cast  any  shadows ; 
second  and  more  frequently,  because  many  objects  cast  a  shadow  near  and  ap- 
parently inside  the  ureter  that  are  not  calculi.     Many  of  the  calculi  are  stopped 


i 


FOREIGN    BODIES    IN    THE    URETER:    URETERAL    CALCULI    635 

in  the  iliac  portiou  near  the  point  where  the  ureter  crosses  the  big  blood  vessels 
and  here  calcareous  concretions  in  the  wall  of  the  artery,  phleboliths  in  the 
vein,  small  bony  prominences  and  calcified  glands  have  all  been  mistaken  for 
calculi,  as  are  the  deceptive  shadows  given  by  a  defective  plate.  In  one  case 
in  which  some  of  the  best  radiogra])liists  in  the  country  told  me  that  there  was 
a  stone  in  the  ureter  at  the  pelvic  l)rim,  1  found  at  operation  that  there  was  sim- 
ply a  spindle-shaped  collection  of  pus  at  this  point.  Sometimes  shadows  are 
t^een  near  the  ureter  and  then  the  question  arises  whether  they  are  really  calculi, 
and,  if  they  are,  whether  they  are  contained  in  a  sacculation  of  the  ureter  or 
in  a  supernumerary  ureter. 

In  order  to  ascertain  the  real  condition,  cystoscopy  and  ureteral  catheteriza- 
tion are  very  imj)ortant.  If  the  ureteral  catheter  is  stopped  at  the  point  where 
the  calculus  is  supposed  to  be,  and  if  a  wax-tipped  catheter  shows  a  definite 
scratch,  the  location  of  the  calculus  may  be  quite  accurately  determined.  If 
all  the  data  agree,  then  the  diagnosis  becomes  more  likely.  If  there  is  a  differ- 
ence between  the  X-ray  findings  and  those  of  ureteral  catheter,  the  examination 
should  be  repeated.  In  doubtful  cases  we  can  resort  to  an  exploratory  incision, 
provided  the  symptoms  warrant  it,  which  will  also  serve  as  the  first  step  of  the 
operation  in  case  a  calculus  is  found.  X-ray  plates  should  be  made  wdtli  a 
catheter  in  the  ureter,  as  this  shows  the  relation  between  the  suspected  stone 
and  the  ureter  quite  definitely. 

A-XTKiA  is  the  alarming  symptom  of  ureteral  calcidus.  Both  ureters  are 
sometimes  blocked  by  calculi,  causing  anuria,  but  such  an  event  is  very  rare. 
It  usually  occurs  after  the  blocking  of  one  ureter.  Formerly  such  cases  were 
described  as  reflex  anuria ;  but  I  now  firmly  believe  that  the  unilateral  block- 
ing of  a  ureter  causes  surgical  anuria  only  when  the  other 
kidney  is  anatomically  absent,  or  its  functionating  power  is  ^^^^% 

temporarily  or  permanently  destroyed.      This  is  important  to  ^^jp'' 

remember    as    having    a    bearing   upon    the    emergency    treat-    Fig.  402. — Actual 

ment   of  calculous   anuria.      It   is   not  necessary   for   a   large        ^^^^  °^  t    ™^'^ 

-^  t>  Giving    Rise    to 

stone  to  block  the  canal  in  order  to  have  anuria,  as  the  great-        Calculous  Anu- 
est  danger  comes  from  a  medium-sized  stone  that  completely        ^^^^^  ■. 
obstructs  the  canal  (Fig.  402). 

We  shall  not  describe  here  in  full  the  symptoms  of  calculous  anuria.  They 
are  those  of  anuria  in  general.  The  duration  of  calculous  anuria  varies  con- 
siderably, according  to  cases ;  sometimes,  after  a  few  hours,  the  calculus  is 
voided  with  symptoms  of  ureteral  colic  and  a  postanuric  polyuria  may  be  ob- 
served, when  it  shoulj:l  be  considered  a  transient  case.  In  other  cases,  the 
anuria  persists  for  days  and  even  for  two  weeks.  (See  chapter  on  Xephro- 
lithiasis,  page  522.) 

The  diagnosis  of  cases  of  calculous  anuria  must  be  made  quickly,  as  a  mis- 
take may  be  very  costly.     The  questions  we  have  to  consider  are  the  foUowdng:- 


636  THE   URETERS 

Is  the  anuria  due  to  calculous  disease  and  is  the  blocking  bilateral  or  unilateral  ? 
If  the  latter,  is  there  another  kidney  and  what  is  its  condition?  Lastly,  what 
should  be  the  nature  of  the  operation  ? 

It  might  be  well  to  relate  here  the  general  course  of  events  that  I  have  no- 
ticed in  the  handling  of  such  cases  by  the  general  practitioner  and  the  urinary 
surgeon. 

When  a  patient  on  arising  in  the  morning  cannot  pass  water  and  goes 
through  the  day  without  urinating,  toward  evening  he  becomes  rather  alarmed 
over  his  condition,  especially  if,  after  trying  to  urinate,  he  cannot  pass  a  drop 
and  he  has  no  sensation  of  pain  nor  vesical  fullness.  He  sends  for  his  physician 
who  comes  and  passes  the  catheter  and  finds  no  urine  in  the  Ijladder.  The 
physician  then  asks  him  if  he  has  had  any  pain  or  colic  in  the  side  or  has  ever 
had  such  an  attack  before.  He  may  remember  that  he  has  had  pains  in  the 
loins  the  night  before  or  at  some  other  time,  or  he  may  not.  The  physician  then 
prescribes  acetate  of  potash,  gr.  x  or  xv,  or  diuretin,  gr.  xv,  every  three  hours, 
or  theocin,  a  grain  every  hour.  He  palpates  the  kidneys  and  if  one  or  both 
are  tender  he  applies  cups.  If  there  are  any  symptoms  of  uremia  or  edema, 
he  may  give  him  some  cathartic,  as  elaterium,  gr.  ^,  or  jalap  powder,  gr.  xxx,  or 
a  hot  pack,  or  some  pilocarpin.  These  having  no  effect,  he  has  a  consultation 
on  the  following  day  and  the  urinary  surgeon  is  called.  Sometimes  the  urinary 
surgeon  is  not  called  for  several  days  until  he  has  passed  through  the  hands 
of  several  physicians  and  uremia  is  threatening  or  present.  The  urinary  sur- 
geon takes  the  patient's  temperature,  pulse  and  blood  pressure,  and  palpates  the 
kidneys  and  the  ureters  over  the  abdominal  portion,  and  in  the  pelvic  portion 
by.  recto-abdominal  palpation  in  men  and  vagino-abdominal  in  women.  If  he 
detects  an  enlargement  of  both  kidneys,  or  a  tenderness  over  both  kidneys  in 
the  loin  or  over  the  lower  ends  of  the  ureters  by  pelvic  examination,  he  suspects 
the  case  to  be  one  of  bilateral  calculous  anuria ;  whereas,  if  he  finds  such  symp- 
toms of  enlargement  and  tenderness  on  but  one  side,  he  considers  it  a  probable 
unilateral  calculous  anuria. 

He  then  examines  the  bladder  by  cystoscopy.  If  he  finds  the  bladder  empty 
and  not  inflamed,  he  looks  for  the  mouths  of  the  ureters  and  watches  to  see  if 
there  is  any  urine  coming  from  them.  If  they  are  not  secreting,  he  catheterizes 
the  ureters.  In  case  the  catheter  meets  with  an  obstruction  in  both  ureters  he 
considers  the  case  one  of  bilateral  calculous  anuria.  In  case  that  the  catheter 
goes  to  the  pelvis  of  the  kidney  on  one  side  and  no  urine  escapes  and  the  second 
catheter  enters  the  other  ureter  for  a  certain  distance  and  then  meets  with  an 
obstruction  beyond  which  it  does  not  pass,  he  believes  that  he  has  to  do  wdth 
unilateral  calculous  anuria,  and  that  the  patient  has  a  functionally  destroyed 
kidney  on  one  side,  and  a  functionally  blocked  kidney  on  the  other  side.  In 
case  the  catheter  goes  to  the  pelvis  of  the  kidney  on  each  side  and  no  urine 
escapes  the  anuria  is  not  due  to  obstruction. 


FOREIGT^    BODIES    m    THE    TTRETEK:    FKETEEAL    CALmj    637 

Treatment. — The  medical  treatment  of  transient  ureteral  stones  or  other 
foreign  bodies  of  the  nreter  is  tlie  same  as  that  o\itlined  for  renal  colic  due  to 
stone  (q.  v.).  The  pain  is  treated  with  morphin  and  chloroform  iidialations;  if 
near  the  bladder,  by  massage  of  the  nreter,  by  rectum  in  men  and  by  the  vagina 
in  women.  Severe  hemorrhage  can  be  treated  with  ergot.  It  would,  however, 
be  a  most  rare  occurrence.  If  stones  do  not  pass  out,  they  become  latent  calculi 
and  the  obstruction  of  the  flow  of  the  urine  will  then  probably  cause  a  gradual 
destruction  of  the  kidney  on  that  side  through  pyelitis  and  pyonephrosis,  and  it 
is  therefore  advisable  to  remove  the  stone  by  ureterotomy.  ISTephrectomy  must 
be  performed  only  \vhen  the  kidney  has  undergone  considerable  sclerosis  and 
atrophy  and  has  no  more  functional  value. 

In  the  case  of  the  unilateral  calculous  anuria,  the  surgeon  immediately 
performs  a  nephrotomy  on  the  kidney  wdth  the  blocked  ureter  and  then  awaits 
developments.  If  the  calculus  passes,  as  it  probably  wall,  then  he  allows  the 
kidney  to  heal ;  but  if  the  calculus  is  not  passed,  then  he  performs  a  ureterot- 
omy and  removes  it. 

If  the  patient  has  a  bilateral  calculous  anuria,  he  might  think  it  advisable  to 
do  a  nephrotomy  on  both  sides,  or  else,  if  one  kidney  was  more  enlarged  and  ten- 
der than  the  other,  he  might  consider  it  wiser  to  do  a  nephrotomy  on  the  kidney 
more  involved  first,  and  the  one  less  involved  at  another  time. 

If  he  performs  first  a  nephrotomy  on  one  side,  he  follows  it  in  a  day  or  two 
with  a  nephrotomy  of  the  other  side.  Personally,  if  I  ever  have  a  case  of  bi- 
lateral calculous  anuria,  I  wall  do  a  double  nephrotomy  unless  the  patient  is  in 
such  bad  condition  that  it  would  be  dangerous  to  operate  on  more  than  one  side 
at  a  time. 

In  cases  of  anuria,  the  oj)eration  is  an  emergency  one.  It  has  been  pro- 
posed to  push  an  impacted  stone  back  into  the  renal  pelvis  by  the  ureteral  cathe- 
ter, but  this  is  not  practicable.  The  intervention  is  nephrotomy,  as  has  already 
been  said,  either  unilateral  or  bilateral,  depending  on  whether  one  or  both 
kidneys  are  involved.  After  the  establishment  of  proper  drainage  of  the  kid- 
ney, the  symptoms  of  anuria  disappear  and  the  intense  congestion  usually 
subsides  sufficiently  in  a  few  days  to  allow  the  calculus  to  pass.  If  it  is  not 
passed,  then  a  secondary  ureterotomy  should  be  performed  to  remove  it,  after 
having  again  catheterized  the  ureter  to  discover  if  it  is  still  present.  These  steps 
seem  to  me  preferable  to  a  primary  ureterotomy. 

One  of  the  most  interesting  cases  of  latent  ureteral  calculi  that  I  have  had 
was  one  of  double  ureteral  calculus  situated  on  either  side  about  three  inches 
Ijelow  the  pelvis  of  the  kidney. 

The  patient  had  had  several  attacks  of  pain  on  the  right  side  during  a 
period  of  two  years,  as  well  as  an  occasional  feeling  of  uneasiness.  There  had 
been  no  symptoms  on  the  other  side.  The  urine  showed  a  few  pus  cells  from 
the  lower  urinary  tract,  a  few  blood  cells,  renal  epithelia  and  hyaline  and  granu- 


638 


THE    URETERS 


lar  casts,  showing  aseptic  interstitial  renal  changes.  Cystoscopie  examination 
sliowed  a  healthy  bladder.  The  ureters  were  catheterized  and  no  obstruction  was 
found,  lladiography  showed  a  stone  in  each  ureter  three  inches  below  the 
pelvis  (Fig.  4(KJ).  The  jjatient  was  treated  for  some  time  by  flushings  of  vari- 
ous mineral  waters  and  internal  remedies  and  the  cpiestion  then  arose  as  to 
the  best  operative  procedure  in  his  case.     The  jirohaliiliries  were  that  the  calculi 


Fig.  403. — Case  of  Double  Ureteral  Calculus.      Each  situated  about  three  inches  below  renal 
pehis.     Radiographic  picture.     (Author's  caso.) 


Avould  gradually  work  themselves  down  to  near  the  bladder  and  there  remain 
unless  operated  upon.  It,  therefore,  seemed  advisable  to  operate  in  the  posi- 
tion in  which  they  then  were.  I  accordingly  did  a  double  loin  ureterotomy  at 
one  operation,  removed  both  calculi,  closed  both  ureteral  wounds  by  ligature, 
leaving  a  drain  in  each  wound  down  to  the  ureteral  opening.  One  ureter  closed 
in  ten  days,  the  other  in  four  weeks. 

The  other  foreign  bodies  in  the  ureter  are  of  much  less  importance.  First 
to  be  considered  are  blood  or  pus  clots  and  impacted  mucous  secretions.  Second, 
foreign  bodies  that  have  been  introduced  through  the  ureter,  as  pieces  of  a 
broken  catheter.     Blood  clots  or  some  foreign  material  entering  from  the  out- 


TUBERCULOSIS    OF    THE    UllETEK  639 

side,  as  spicules  of  bone,  tissue  or  clotliiiii:-,  due  Id  1raiiiii;itisiii^  may  cause  ob- 
struction ;  the  former  through  becoming  surrounded  by  urinary  salts  and  form- 
ing a  calculus,  the  latter  through  forming  the  nucleus  of  a  calculus  or  by 
causing  a  raw  surface  on  which  urinary  salts  can  be  dejx>sited  in  connection  with 
iiiiu'us  or  ])us.  Both  of  these  conditions  of  traunuUism  avouM  be  more  likely 
to  occur  when  strictured  or  sacculated  ureters  are  wounded  lhau  iu  llic  uonnal 
state  and  are  causative  factors. 

TUBERCULOSIS    OF   THE   URETER 

Etiology. — The  study  of  tuberculosis  of  the  ureter  is  to-day  of  but  little 
importance,  as  the  disease  usually  occurs  first  in  one  kidney  and  then  descends 
through  the  ureter  to  the  bladder,  and  the  rule  of  renal  surgery  is  to  remove 
a  tuberculous  kidney  as  soon  as  the  diagnosis  is  made,  providing  the  other 
kidney  is  sufficiently  healthy  to  carry  on  the  process  of  elimination.  A  tuber- 
culous ureter  is  therefore  but  an  appendage  of  a  tuberculous  kidney  and  should 
be  considered  as  such.  It  usually  atrophies  as  soon  as  the  kidney  heals,  ceases 
to  functionate,  or  is  removed.  Primary  tuberculosis  of  the  ureter  almost 
never  occurs  and  secondary  tuberculosis  is  therefore  the  form  to  be  considered. 

Secondary  tuberculosis  of  the  ureter  has  been  known  to  follow  tuberculosis 
of  some  of  the  neighboring  tissues,  as  tuberculosis  of  the  spine ;  but  it  is  almost 
always  secondary  to  a  tuberculous  infection  of  the  bladder  or  kidney.  In  the 
former  instance,  it  is  called  ascending,  and,  in  the  latter,  descending  tubercu- 
losis. It  is  very  difficult  for  a  tuberculous  infection  to  travel  up  from  the  blad- 
der against  the  urinary  current,  whereas  it  is  comparatively  easy  for  it  to 
descend  from  the  kidney.  Ureteral  tuberculosis  is  consequently  in  most  cases 
a  secondar}^  descending  process  from  the  kidney.  As  renal  tuberculosis  is  uni- 
lateral in  over  fifty  per  cent  of  the  cases  that  we  see  clinically,  ureteral  tuber- 
culosis will  probably  be  found  on  but  one  side  in  the  same  proportion  of  cases. 

The  entire  length  of  the  ureter  is  more  commonly  involved  than  local  areas 
of  the  canal.  When  the  lesions  are  situated,  however,  in  but  one  part  of  the 
ureter,  they  are  usually  found  near  the  upper  or  lower  end,  in  which  latter  case, 
as  when  it  involves  the  entire  canal,  the  infection  extends  to  the  bladder. 

Pathology. — Tuberculous  ureteritis  begins  with  miliary  granulations  upon 
the  surface  of  the  mucosa,  which  later  coalesce  and  ulcerate.  Deep-seated  tu- 
berculous infiltration  may  take  place,  giving  rise  to  elevations  and  protrusions 
into  the  canal  which  may  obliterate  the  lumen.  The  whole  extent  or  only  iso- 
lated foci  of  the  ureteral  tract  may  be  involved.  Complete  obstruction  mux 
occur  through  cicatrization,  or  occlusion  of  the  canal  by  the  protrusions  asso- 
ciated with  deei>seated  infiltration,  and  the  ureter  may  finally  become  merely  a 
thick,  fibrous  cord. 

As  the  tuberculous  changes  may  be  arrested  at  any  period  in  the  process, 


640 


THE    URETERS 


the  appearance  of  the  ureter  and  kidney  at  autopsy  varies  according  to  the  li)cal- 
itj  and  character  of  the  involvement.  In  some  cases,  the  two  ureters  and  kid- 
neys may  present  an  entirely  different  aspect. 

If  the  process  is  localized,  the  tuberculous  thickening  usually  occurs  at  the 
ends  of  the  nreters,  in  which  case  the  canal  above  may  be  dilated  and  its  sur- 
face occupied  by  su- 
perficial ulcers  (Fig. 
404).  If  the  upper 
part  of  the  canal  is 
involved,  the  effect  is 
the  same  as  if  the 
whole  ureter  were 
thickened  and  dila- 
tation takes  place  in 
the  renal  pelvis. 
More  frequently,  the 
whole  nreter  is  in- 
volved, the  tubercu- 
lous infiltration  with 
thickening  and  mixed 
infection  resulting  in 
a  short,  thick  nreter. 
The  tuberculous 
infiltrations  develop 
so  rapidly  and  are  at 
times  so  packed  in 
the  canal,  that  oc- 
clusion, unilateral 
annria  and  atrophy 
of  the  kidney  on  the 
affected  side  occur. 
If  the  process  is 
slower  and  the  ob- 
struction less,  the 
urine  continues  to 
flow  through  the  nreter,  but  the  impediment  will  suffice  to  cause  back  pressure 
and  pyonephrosis.  Tnbercnlosis  of  the  lower  part  of  the  nreter  extends  to  the 
bladder,  where  it  is  seen  in  the  form  of  tnbercles  and  nlcers  about  the  mouth  of 
the  nreter  on  the  trigone. 

Symptoms.— The  symptoms  of  nreteral  tuberculosis  closely  resemble  those 
of  renal  tuberculosis  in  that  they  are  usually  not  marked  and  often  absent. 
The  characteristic  renal  pains  may  be  present  in  a  pronounced  form,  or  else 


Fig.  404. — Tuberculosis  of  the  Ureter.  The  right  shows  a  stricture 
just  below  the  pelvis  and  a  tuberculous  thickening  just  above  the 
bladder.  Between  these  two  points  is  a  dilatation  of  the  canal  and 
a  flat  tuberculous  ulcer. 


STRICTURE    OF    THE   URETER  641 

entirely  absent,  when  the  disease  progresses  slowly.  Renal  colics  sometimes 
occur,  clue  to  passing  masses  of  debris  from  the  kidney  through  a  strictured 
ureter.  Sometimes  there  is  a  dull  pain  radiating  from  the  iliac  fossa  toward 
the  groin  or  the  bladder,  or  else  up  toward  the  lumbar  region.  This  pain  may 
be  intensified  by  deep  pressure  over  the  kidney.  Pain  in  the  bladder  with 
tenesmus  and  frequency  of  urination,  which  occurs  when  the  process  has  reached 
the  bladder,  may  be  the  first  symptom  of  tuberculous  ureteritis. 

Examination. — The  thickened  ureter  can  sometimes  be  felt  through  the 
abdominal  wall  and  is  tender  on  pressure;  whereas,  in  more  advanced  cases,  it 
is  a  tough  fibrous  band.  In  women,  bimanual  palpation  will  sometimes  show 
per  vaginam,  a  large  tender  ureter,  Avhen  the  lower  end  is  affected.  In  men, 
it  is  more  difficult  to  palpate  the  lower  end  of  the  ureter  by  rectal  touch,  al- 
though, if  pressed  upon,  it  may  give  rise  to  a  pain  radiating  along  the  course 
of  the  duct  to  the  bladder  or  kidney.  A  cystoscopic  examination  shows  small 
ulcers  about  the  mouth  of  the  ureter  if  the  whole  duct  or  its  lower  end  is  involved. 

Diagnosis. — The  diagnosis  depends  upon  our  being  able  to  palpate  the  thick- 
ened ureter  in  some  parts  of  its  course,  together  with  the  presence  of  a  tuber- 
culous kidney  on  that  side  and  the  presence  of  ulcerations  in  the  bladder  around 
the  orifice  of  the  ureter,  as  seen  through  the  cystoscope.  The  passage  of  the 
ureteral  catheter  shows  the  narrowing  of  the  lumen  of  the  canal,  and  the  urine 
drawn  from  the  pelvis  on  that  side  contains  tubercle  bacilli. 

Prognosis. — Tuberculosis  of  the  ureter  may  undergo  resolution  as  well  as 
the  kidney.  After  the  corresponding  kidney  has  been  destroyed  or  removed, 
the  ureter  may  be  transformed  into  a  band  of  fibrous  tissue,  or  it  may  continue 
to  discharge  or  form  a  pus  sac  in  a  part  or  the  whole  of  the  canal. 

Treatment. — Remove  the  kidney  if  it  be  tuberculous,  with  a  part  or  all  of 
the  ureter,  if  the  other  organ  is  normal.  I  have  never  had  any  trouble  with  the 
ureter  after  nephrectomy  in  these  cases.  I  ligate  it  and  cauterize  the  lumen  of 
the  stump  just  below  the  renal  pelvis.  I  feel,  however,  that  it  is  safer  to  attach 
the  ligated  segment  to  the  skin  or  the  external  fascia  in  the  loin,  so  as  to  be  able 
to  find  it  easily  if  pus  or  urine  should  accumulate  in  it. 

STRICTURE   OF  THE  URETER 

Etiology. — Contractions  of  one  or  both  ureters  may  occur  at  either  end  of 
the  canal  or  in  its  middle.  There  are  two  forms  of  stricture — the  congenital  and 
the  acquired.  The  congenital  form  is  usually  situated  at  the  junction  of  the 
ureter  with  the  pelvis.  The  acquired  stricture  usually  occurs  at  one  of  the 
normally  narrow  points  of  the  canal.  Acquired  stricture  may  occur  at  any  age. 
It  may  be  due  to  irregularities  of  the  vascular  supply,  the  canal  being  crossed 
and  strangulated  by  an  anomalous  vessel.  The  stricture  may  also  result  from 
scar-tissue  contraction  following  an  ulceration  in  tuberculous  ureteritis   (Tig. 


642 


THE   UKETEKS 


405)  or  an  impacted  calculus  of  the  ureter.    It  may  also  be  due  to  tuberculous 

111  other  cases,  it  may  be  caused  by  a 
periureteral  thickening  or  adhesions, 
or   due  to   an   injured   ui-eter  \vitli   an 


deposits  "with  thickening  of  the  canal. 


accumulation  of  pus  or  urine  about  it, 
A  stricture  of  one  portion  may  be  asso- 
ciated with  the  dilatation  of  another. 
In  women,  the  right  side  is  principally 
affected. 

Pathology. — A  valve  of  mucous 
membrane  is  frequently  found  at  the 
junction  of  the  ureter  and  the  renal 
pelvis,  giving  rise  to  obstruction.  This 
may  be  either  congenital,  or  acquired 
by  pathological  changes  in  the  mucosa 
of  the  renal  pelvis  or  the  ureter  itself. 
Ureteral  valves  have  been  observed  in 
kinked  and  twisted  ureters  at  the  point 
of  flexion. 

In  tuberculosis  of  the  ureter, 
strictures  are  seen  as  the  result  of 
contraction  of  scar  tissue  after  ul- 
cerations. In  other  tuberculous  cases, 
thickened  ureters  are  found  which 
are  more  marked  in  some  places  than 
in  others,  so  that  the  lumen  is  either 
very  much  narrowed  or  totally  oc- 
cluded (Fig.  405).  Irregularities  and 
saccular  dilatations  with  narrowing 
in  places  are  seen  in  ureters  as  the 
result  of  long-standing  inflammations 
(Fig.  397).   ^ 

Symptoms. — The  symptoms  are  vague,  ill-defined  and  misleading.  The 
associated  complications  are  often  more  striking  than  the  trouble  itself.  A 
partially  obstructed  ureter  often  gives  rise  to  an  enlargement  and  displacement 
of  the  corresponding  kidney,  in  which  case  the  organ  can  be  felt  as  enlarged  and 
tender  on  pressure.  It  may  be  accompanied  by  symptoms  of  malaise  and  ten- 
derness, which  condition  subsides  later  temporarily.  Occasionally  the  ureter 
above  the  stricture  can  be  outlined  as  a  very  much  dilated  duct ;  but  it  occurs 
very  rarely  and  I  have  never  been  able  to  palpate  the  ducts  through  the  abdo- 
men, even  when  autopsy  has  shown  them  to  be  much  enlarged.  Sometimes 
attacks  of  pain  occur  in  the  kidney  on  that  side  when  small  calculi,  masses  of 


Fig.  405. — Thickening,  Dilation,  Ulcera- 
tion AND  Strictures  that  are  Seen  in 
Fig.  404,  More  Clearly  Shown.  (Author's 
case.) 


FISTULAS   OF   THE   UEETERS  643 

crystals  or  tuberculous  detritus  are  passing  through  the  strictured  canal.  Gastro- 
intestinal symptoms  are  sometimes  observed,  as  are  also  peculiar  sensations  in 
the  rectum. 

Diagnosis. — Strictures  of  the  ureter  never  exist  without  pathological  con- 
ditions of  other  parts  of  the  tract  and  the  symptoms  of  this  condition  are  iden- 
tical Avith  those  of  renal  retention  or  hydronephrosis.  The  existence  of  the 
stricture  and  its  exact  location  is  frequently  unknown  until  discovered  by  ure- 
teral catheterization  or  in  the  course  of  surgical  procedures. 

Treatment. — Gradual  dilatation  by  ureteral  catheter  may  be  of  service  in 
strictures  that  are  neither  very  tight  nor  unyielding,  but  it  is  often  useless  and 
may  cause  traumatism.  It  should  not  be  resorted  to  if  it  causes  pain  or  fever. 
A  longitudinal  ureterotomy  followed  by  a  transverse  suture  is  the  most  satisfac- 
tory procedure,  unless  there  is  too  much  thickening. 

In  stricture  of  the  upper  part  of  the  canal,  the  duct  may  be  divided  and  the 
end  of  the  distal  segment  implanted  into  the  lower  part  of  the  pelvis ;  whereas, 
when  it  is  near  the  bladder,  the  end  of  the  proximal  segment  may  be  implanted 
into  the  bladder  in  the  same  way.  Resections  with  end-to-end  sutures  are  indi- 
cated in  stricture  of  the  middle  third  of  the  canal.  Xephrectomy  can  be  per- 
formed in  advanced  cases  of  pyonephrosis  in  which  the  kidney  is  almost 
destroyed. 

In  conclusion,  it  may  be  said  that  the  grave  results  of  neglected  ureteral 
stricture  justify  an  exploratory  operation  in  the  loin  w^henever  symptoms  of 
ureteral  stenosis  are  present  that  cannot  be  accounted  for  by  the  regular  methods 
of  routine  examination. 

FISTULAS   OF  THE  URETERS 

Fistulas  of  the  ureters  are  communications  between  the  ureters  and  either 
the  skin  or  some  hollow^  viscera  in  the  abdomen  or  pelvis. 

Etiology. — The  causes  of  fistulas  are  either  in  the  ureter  or  from  the  out- 
side. The  internal  causes  are  the  result  of  a  perforation  of  the  ureter,  due  to  a 
tuberculous  ulcer  or  an  epithelioma,  which  has  caused  a  local  destruction  of 
the  wall ;  or  else  it  is  due  to  a  stone  which  has  caught  in  the  canal  and  either 
perforated  it  or  caused  a  slough,  resulting  in  the  urine  leaking  into  the  sur- 
rounding tissues.  The  sloughing  of  the  ureter  may  also  occur,  due  to  a  gravid 
uterus  pressing  upon  it  during  pregnancy,  especially  when  there  has  been  a 
prolonged  labor.  It  usually  occurs  on  the  left  side  where  it  is  pressed  upon  by 
the  fetal  head. 

Traumatic  fistulas  may  be  the  result  of  any  injury  inflicted  accidentally 
or  during  operation. 

Pathology. — The  urine,  having  leaked  into  the  neighboring  tissues,  gives 
rise  to  urinary  abscess,  which  points  either  on  the  surface  of  the  body  or  some 


644  THE   URETERS 

mucous  surface.  The  fistulous  opening  is  either  transverse  or  longitudinal,  of 
variable  shape  and  size.  If  longitudinal,  the  urine  leaks  from  the  sides  of  the 
duct ;  but  if  the  wound  has  been  transverse  and  complete,  it  will  escape  from 
the  upper  end,  which  may  retract  after  the  injury.  Transverse  wounds  are 
usually  the  result  of  a  surgical  injury. 

The  place  in  which  the  abscess  discharges  is  the  distal  end  of  the  fistulous 
tract,  as  the  abdominal  wall  anteriorly  or  posteriorly ;  or  into  the  bowel,  duo- 
denum, colon,  rectum ;  or  into  the  stomach,  the  latter  being  extremely  rare. 
Fistulas  may  also  open  into  the  vagina  or  into  the  uterus ;  and  in  some  cases, 
when  the  rupture  of  the  ureter  is  at  the  point  where  it  enters  the  bladder,  both 
the  ureter  and  the  bladder  may  empty  into  the  vagina.  The  ureteral-vaginal 
and  the  ureteral-uterine  fistulas  are  the  result  of  lesions  of  the  lower  portion  of 
the  duct,  while  the  cutaneous  fistulas  are  nearly  always  the  result  of  injuries 
to  the  upper  portion. 

When  the  wounded  ureter  makes  a  fistulous  opening  into  the  uterus  or  the 
vagina,  the  communication  may  be  direct  from  one  cavity  to  the  other  without 
any  fistulous  tract;  whereas,  in  the  middle  and  upper  third  of  the  ureters,  an 
abscess  always  forms  outside  of  the  canal,  resulting  in  the  tract  extending  from 
the  point  of  leakage  in  the  ureter  to  the  point  of  discharge.  When  the  ureter 
has  been  severed  and  the  two  segments  lie  in  the  abscess  cavity,  the  lower  may 
become  gradually  atrophied.  The  fistulous  tract  is  thickened,  indurated  and 
perhaps  lined  with  granulation  tissue,  the  same  as  the  tract  of  any  sinus. 

Symptoms. — Constant  leakage  of  urine  is  always  present.  The  quantity 
escaping  from  a  fistula  which  is  the  result  of  a  complete  transverse  injury  to  the 
canal  is  greater  than  that  coming  from  a  ureter  which  has  had  only  an  injury 
of  one  side  of  its  wall.  After  a  kidney  has  been  removed,  if  the  ureter  has  not 
been  tied,  a  urinary  fistula  may  occur  at  the  cut  end  of  the  duct  and  the  urine 
may  leak  up  through  it  from  the  bladder.  This,  however,  is  very  rare,  and  is 
due  to  a  dilated  ureter,  the  result  of  obstruction  lower  down  the  urinary  tract. 

Ureteral  fistulas  rarely  heal  spontaneously.  These  fistulas  are  often  com- 
plicated by  recurrent  abscesses,  which  tend  to  bring  the  patient's  health  below 
par.  Strictures  of  the  ureter  also  frequently  occur  at  its  point  of  leakage,  and 
the  resulting  interference  with  the  urinary  flow  may  be  so  marked  as  to  lead 
to  hydronephrosis  and  suppurative  disease  of  the  kidney. 

Diagnosis. — It  is  difficult  to  differentiate  between  a  leakage  coming  from  the 
upper  part  of  the  ureter  and  one  from  the  pelvis  of  the  kidney ;  it  can  simply 
be  surmised  by  noting  the  direction  of  the  fistulous  tract,  as  it  would  require 
an  operation  and  dissection  along  this  tract  to  be  sure  as  to  the  seat  of  the  fis- 
tula. It  is  easier  to  distinguish  the  ureteral  from  the  bladder  fistulas,  as  in 
the  latter  case,  if  methylene  blue  is  injected  into  the  bladder,  it  will  escape  as 
a  blue  fluid  into  the  fistulous  opening.  The  tract  of  the  ureteral  fistula  can 
also  be  discovered  by  injecting  methylene  blue  into  the  tissues  and  noting  if 


FISTULAS    OF    THE    URETEES  645 

it  escapes  from  the  uterine  canal  or  the  vagina  in  cases  where  such  fistulous 
openings  are  suspected. 

Prognosis. — The  greatest  danger  of  these  fistulas  is  tlie  formation  of  a 
stricture  of  the  canal,  causing  obstructions  which  give  rise  to  suppurative  dis- 
eases of  the  kidney. 

Treatment. — The  management  of  ureteral  cutaneous  fistulas  ranges  from 
wearing  some  receptacle  on  the  surface  of  the  body  to  collect  the  escaping  urine, 
to  the  removal  of  the  kidney.  Ureteral  leakage  caused  by  traumatism  in  the 
course  of  an  abdominal  operation  should  be  repaired  by  suture.  If  it  is  a  com- 
plete division  of  the  ureter,  the  ends  should  be  united  by  end-to-end  or  lateral 
anastomosis ;  whereas  lateral  leaks  can  often  be  repaired  by  suture.  When  these 
fistulas  occur  spontaneously,  it  is  almost  always  due  to  impacted  calculus,  which 
should  be  removed  and  the  duct  then  repaired  by  suture.  While  this  operation 
is  being  performed  and  until  healing  takes  place,  a  ureteral  catheter  should  be 
retained  in  the  canal.  Sometimes  if  a  catheter  is  simply  retained  in  the  canal 
for  some  time,  it  will  allow  a  healing  of  a  lateral  injury.  If  the  kidney  has 
developed  a  suppurative  process  that  is  dangerous  to  life,  it  can  be  removed. 
If  the  urine  continues  to  leak  from  the  bladder  through  the  ureter  after  a 
nephrectomy,  the  ureter  should  also  be  removed.  Another  method  of  treating 
such  a  case  would  be  by  the  Watson  operation,  which  comprises  a  lumbar  in- 
cision, then  ligating  the  ureter,  opening  the  pelvis  of  the  kidney  by  a  vertical 
incision  through  the  convexity  of  the  kidney,  inserting  a  drainage  tube  into 
the  kidney  pelvis  and  draining  directly  into  the  receptacle  on  the  back  of  the 
patient.  This  would  often  save  a  large  amount  of  functionating  renal  tissue 
that  is  lost  by  performing  nephrectomy. 


CHAPTEE    XXXIII 

OPERATIONS   ON   THE   URETER 

The  operations  on  the  ureter  are  as  follows : 

Ureterotomy :  Incising  the  ureter  for  ureteral  calculus  or  stricture. 

Ureterorrhaphy :  Repairing  partial  ureteral  wounds,  that  is,  a  ureter  not 
completely  severed,  as  those  made  during  operations. 

Uretero-ureterostomy :  Implanting  ureter  into  ureter.  End-to-end  anasto- 
mosis, usually  performed  for  complete  wounds  of  the  ureter. 

Ureterostomy:  Implanting  the  end  of  the  cut  ureter  into  the  skin. 

Uretero-cystostomy,  trans-  and  extraperitoneal:  Implanting  the  ureter  into 
the  bladder.  Usually  performed  for  wounds  of  the  ureter  made  during 
operation. 

Uretero-vaginal  anastomosis. 

Uretero-intestinal  anastomosis. 

Ureterectomy :  The  removal  of  a  part  or  the  whole  of  the  ureter.  The  for- 
mer usually  prior  to  an  anastomosis,  the  latter  after  a  nephrectomy  for  a 
tuberculous  kidney. 

]^^ephro-ureterectomy :  The  removal  of  both  kidney  and  ureter  at  the  same 
operation. 

URETEROTOMY 

Ureterotomy  consists  in  cutting  into  the  ureter,  usually  in  the  case  of  stone 
or  stricture.     In  the  first  instance,  it  is  spoken  of  as  uretero-litliotomy. 

Ureterotomy  for  Stoxe 

Ureterotomy  for  stone,  or  uretero-lithotomy,  will  be  the  first  considered,  as 
it  is  performed  in  all  parts  of  the  canal  and  consequently  shows  all  the  various 
incisions  that  are  employed. 

The  patient  should  be  cystoscoped  and  the  ureters  catheterized.  The  in- 
cision is  then  made  in  the  region  that  will  give  the  easiest  approach  to  the 
stone. 

For  stone  in  the  upper  part  of  the  ureter,  the  regular  curved  lumbar  incision 
is  made  in  the  kidney  triangle,  as  for  nephrotomy,  with  the  patient  lying  face 
646 


UKETEROTOMY 


647 


downward   with  a   ])ill()w  or  sand  bai^  under  tlic  abdomen,  or  on  the  healthy 
side  with  I  he  L»in  supported.     The  ureter  is  felt  for  below  the  kidney.     This 

can  be  easily  found  and  delivered,  especially  if  there 
(T^  m  11  is  a  catheter  in  the  ureter.     The  ureter  can  then  be 

freed  and  exposed  from  the;  kidney  to  the  crest  of  the 
ilium  l)v  steadvini;-  the  ureter  with  one  hand  and  sev- 


A 


12  3 

Fig.  406. — Instruments  for  Ure- 
ter Operations  to  be  Used  in 
Addition  to  those  Already 
Mentioned  for  Kidney  Op- 
erations. 1,  Blunt  hook.  2, 
Ureteral  clamp.  3,  Sharp-point- 
ed scissors. 


Fig.  407  A. — Ureterotomy  for  Stone.  Curved  lumbar  incision 
showing  the  delivery  of  the  ureter  below  the  kidney.  (After 
Pierre  Duval.) 


ering  the  tissues  over  it  on  the  outer  side  with  a  thin  knife  or  scissors  (Fig. 
407,  A  and  B). 


Fig.  407  B. — Ureterotomy  for  Stone.     Method  of  freeing  and  exposing  the  duct  and  enlarging  the 
field  prior  to  operation.      (After  Pierre  Duval.) 


648 


OPERATIONS  ON  THE  URETER 


For  a  stone  in  the  middle  or  iliac  portion  of  the  canal,  the  patient  is  placed 
on  his  back   and   an   incision  made   down  to   the   peritoneum,   either   through 


Fig.  408. — Ureterotomy  for  Stone.  Patient  on  his  back  and  the  incision  made  through  the  obliquej 
and  transversalis  muscles  in  the  Uiac  region,  exposing  the  ureter  as  it  crosses  the  pelvic  brim  and} 
iliac  vessels.  The  same  exposure  is  obtained  by  an  incision  through  the  lower  portion  of  the  rectuaj 
abdominis  muscle. 

the  oblique  and  trans- 
versalis muscles,  jnstj 
above  Poupart's  liga- 
ment (Fig.  408),  or  I 
through  the  belly  of| 
the  rectus  muscle  on! 
that  side. 

For  the  operation! 
on  the  lower  or  pelvicj 
ureteral  segment,  the] 
same  incision  should] 
be  made,  but  the  pa-1 
tient  should  be  placed! 
in  the  Trendelenburg] 
position  and  the  epi- 
gastric artery  ligatedj 
and  cut  (Fig.  409). 

The    perineal    in- 1 
cision,     with     a     dis- 
section    up     between  i 

Fig.  409. — Ureterotomy  for  Stone.     Patient  on  his  back,  but  in  the      ,  j     4.1, 

Trendelenburg  position.     The  same  incision  is  seen  and  two  ligatures  tue     prOState     anCi     tnej 

are  noted  about  the  epigastric  artery,  which  when  ligated  and  cut  will  pectum       is      anotherl 
give  a  better  field  for  working  on  the  lowest  segment  of  the  ureter. 

(After  Pierre  Duval.)  method      of      perform-J 


UEETEROTOM^ 


649 


ing  ureterotomy  on  tlie  lowest  pelvic  portion  of  tlie  ureter  in  men.  I'lie 
vai>'inal  incision  is  often  employed  for  stones  in  this  part  of  the  canal  in 
Avomen. 

The  part  of  the  ureter  running  through  the  bladder  wall  is  best  approached 
by  a  suprapubic  opening  of  the  bladder. 

The  calculus  is  usually  at  the  lower  end  of  the  ureter.  In  aseptic  cases, 
there  is  some  thickening  at  the  level  of  the  calculus  and  some  dilatation  above 
it ;  wdiereas,  in  septic 
cases,  there  is  an  in- 
flammation, thickening 
and  perhaps  a  localized 
peritonitis  and  a  stric- 
ture below  the  calcu- 
lus. It  is  necessary 
to  remove  the  stone  to 
have  the  ureter  drain 
the  kidney  well. 

Technique  of  Op- 
eration through  Ab- 
dominal Incisions 
(Abdominal  Ureterot- 
omy).— The  patient  is 
cystoscoped  and  the 
ureter  catheterized,  the 
catheter  usually  pass- 
ing by  the  calculus. 
If  it  does  not  pass  the 
stone,  it  will  go  as  far 
as  the  point  where  the 
calculus  is  located. 

Extraperitoneal 
Operation. — The  ure- 
ter is  approached  by 
separating  the  perito- 
neum from  the  lateral 
or  posterior  abdominal 
walls  and  drawing  it 
with  its  contents  to  the 
opposite  side  until  the 
duct  is  seen  in  the  re- 
gion in  which  the  stone  is  situated.  The  duct  is  then  conqn-essed  above  the 
calculus  with  a  piece  of  gauze,  tape  or  a  clamp  to  prevent  urine  from  leaking 


Fig.  410. — Ureterotomy  for  Stone.  The  same  position  and  incision 
as  in  Fig.  409.  A  bulging  of  the  ureter  near  the  bladder  with  an 
incision  in  its  wall  shows  a  deep-seated  calculus.  A  clamp  has 
been  placed  above  it  to  keep  the  urine  from  the  wound  during  the 
operation.     (Jeanbrau.     L'Ass.  Frangaise  d'Urologie.) 


650 


OPERATIONS  ON  THE  URETER 


into  the  wound,  and  the  calcnhis  is  extracted  hy  forceps;  or  it  may  ho  dis- 
lodged with  a  pair  of  hliint-poiutod  curved  scissors   (Fig.  411). 


\. 


alK^' 


h 


•mawK^ 


Fig.  411. — Ureterotomy  for  Stone.  The  delivery  of  the  calculus,  the  clamping  of  the  ureter,  and 
the  suturing  of  the  abdominal  wall  shown  here  applies  to  any  part  of  the  ureter.  In  the  upper 
figure  the  calculus  is  being  dislodged  by  blunt-pointed  curved  scissors,  although  forceps  or  very 
small  dull  curettes  are  generally  used.  The  ureteral  catheter  can  now  be  j^ushcd  up  the  canal  and 
the  duct  closed  by  interrupted  sutures  of  No.  1  chromic  gut  in  a  thin,  round  needle.  (Jeanlirau. 
L'Ass.  Fran9aise  d'Urologie.) 

In  pus  cases,  it  is  necessary  to  proceed  with  greater  care,  as  there  is  present 
a  peri-ureteritis,  the  tissues  are  thicker  and  the  traumatism  connected  with  the 
operation  is  consequently  greater. 

In  case  there  is  no  pus  about  the  calculus,  the  ureter  may  he  opened  just 


URETEROTOMY 


651 


above  it  and  the  stone  reuiovctl ;  but  in  case  there  is  considerable  pus  in  the 
cavity  in  which  the  stone  is  held,  the  duct  should  be  opened  over  the  entire 
length  of  the  calculus. 

Closing  of  ilic  Ureter. — Tlic  ureter  in  clean  cases  is  closed  with  inter- 
rupted sutures  of  the  finest  cliroiiiic  catgut  threaded  in  a  fine  round  intestinal 
needle.  As  the  duct  is  dihitcd  above  the;  stone,  there  is  sufficient  space  for  pass- 
ing the  sntnres. 

Many  do  not  believe  in  sntnres  and  prefer  to  leave  the  wonnd  open.  At 
the  present  writing,  I  think  that  it  is  better  in  all  cases  to  close  the  canal  en- 
tirely, or  at  each  end,  and  to  pass  a  drain  down  to  it  throngh  the  abdominal 
wall.  Pus  can  drain  along  the  ureter  and,  if  the  wound  breaks  down,  the  open- 
ing will  not  be  so  large  as  when  the  entire  incision  is  left  open.  It  is  much 
easier  to  close  the  ureter  when  a  ureteral  catheter  has  been  passed  up  the  ureter 
before  the  operation  (Fig.  411).     If  this  has  not  been  done,  a  catheter  can  be 


Fig.  412. — Ureterotomy  for  Stone.  A  ureteral  catheter  is  an  aid  in  suturing  the  ureter,  but  when 
it  is  not  used,  any  small  woven  catheter  should  be  passed  into  the  ureter  from  the  wound  and 
removed  as  soon  as  the  sutures  are  placed  prior  to  ligating  them.  A  ureteral  catheter  is  prefer- 
able, however,  both  as  an  aid  when  suturing  the  duct,  as  a  drain  for  the  kidney,  and  to  prevent 
contraction  of  the  field  of  operation.     (Jeanbrau.     L'Ass.  Frangaise  d'Urologie.) 


passed  down  through  the  canal  from  the  field  of  operation,  as  it  is  easier  to 
suture  the  canal  when  an  instrument  is  in  it.  The  sutures  are  interrupted  and 
pass  through  the  entire  wall  excepting  the  mucous  coat.  In  case  a  catheter  has 
been  introduced  from  the  field  of  operation,  it  should  be  withdrawn  before  the  su- 


652 


OPERATIONS  ON  THE  URETER 


tures  are  ligated  (Fig.  412).   In  any  case,  a  ureteral  catheter  passed  through  the 
urethra  and  bladder  by  the  field  of  operation  should  be  retained  for  some  time. 
Closing  of  the  Abdomen. — The  drainage  and  the  closing  of  the  abdom- 
inal wound  should  be  the  same  in  septic  as  in  aseptic  cases,  except  that  the 

wound  should  not  be  closed 
tightly  up  to  the  drainage 
tube ;  but  space  should  be 
left  for  better  placing  the 
drain,  as  drainage  will 
probably  have  to  be  kept 
up  for  four  to  fourteen 
days  or  longer.  The  ure- 
teral catheter  may  have  to 
remain  in  the  ureter  from 
a  week  to  a  month,  ac- 
cording to  the  healing  proc- 
ess. The  ureteral  catheter 
should  be  changed  every 
few  days  or  at  least  once  a 
week,  for  the  sake  of  clean- 
liness, even  when  it  is 
working  well.  The  renal 
pelvis  can  be  washed  out 
once  or  twice  a  day,  ac- 
cording to  the  drainage, 
with  warm  water,  followed 
by  silver,  1 :  4,000,  or  pro- 
targol,  1:400. 

Teanspekitoneal 
Route.  —  In  women,  the 
transperitoneal  route  seems 

Fig.  413. — Incision  through  the  Broad  Ligament,  Exposing  tO   DC  the  one  01  clioice  lOr 

THE  Ureter  on  One  Side.      The  round  ligament  has  been  -nglvic    WOrk    on   the    Uretcr 

cut  through  and  the  vessels  about  the  ureter  are  seen.     In  this  .           , 

locality,  ureterotomies,  ureterorrhaphies,  ureteral  anastomosis,  lOI"  tWO   reaSOns  '.   J:  irst,    DC- 

uretero-vesical  anastomosis,  uretero-intestinal  anastomosis  can  rause    the    iniuries    tO    the 
all  be  done.     When  one  of  these  operations  has  been  performed, 

an  extraperitoneal  incision  can  be  made  for  drainage  through  ureterS  usually  happen  Clur- 

the  loin,  groin,  or  vagina  and  the  peritoneum  can  be  closed  •          onerations    and    are   of- 

over  the  operative  field.     (After  Pierre  Duval.)  &      1 

ten  seen ;   and  second,  be- 
cause by  the  abdominal  incisions,  either  through  the  oblique  group  of  muscles  or 
through  the  rectus,  more  difficulties  are  found  in  separating  and  drawing  aside 
the  peritoneum  from  the  pelvic  wall  by  the  extraperitoneal  operation  than  in  men. 
In  the  case  of  discovering  later  that  a  ureter  has  been  injured  during  opera- 


UEETEROTOMY 


653 


tion,  it  is  easier  to  open  the  abdomen  again  and  retrace  one's  steps  than  to  try 
to  find  a  partially  wounded  ureter  or  the  segments  of  one  that  has  been  com- 
])letely  severed  by  the  extraperitoneal  route. 

It  is  important  in  performing  such  operations  in  the  female  to  remember 
that  the  pelvic  portion  of  the  ureter  runs  from  the  bifurcation  of  the  iliac  ves- 
sels to  the  base  of  the  bladder,  and  that  the  portion  of  it  in  these  cases  that  is 
liable  to  be  injured  is  behind  the  broad  ligament. 

Fig.  413  shows  a  dissection  through  the  broad  ligament  exposing  the  ureter 
on  the  left  side.  The  round  ligament  has  been  cut  through  and  the  vessels 
about  the  ureter  are  seen.  In  this  locality,  ureterotomy,  ureterorrhaphy,  ure- 
teral   anastomosis,    uretero-vesical    anastomosis,    nretero-intestinal    anastomosis 

can  all  be  done.     Af-      _^ 

ter    they    have    been  ^   ^ 

performed,  the  peri- 
toneum can  be  closed 
over  the  operative 
field  and  a  drain 
passed  down  to  the 
line  of  peritoneal 
closure  through  the 
abdominal  incision. 
In  cases  with  pus  or 
pus  in  the  urine,  it 
is  advisable,  before 
bringing  the  perito- 
neum over  the  plas- 
tic work  on  the  ure- 
ter, to  make  counter 
openings  to  the  sur- 
face above  Poupart's 
ligament  if  the  op- 
eration is  near  the 
bifurcation  of  the 
iliac  vessels,  or 
through  the  vault 
of  the  vagina  on 
that  side  if  the  op- 
eration is  near  or 
connected  with  the 
bladder. 

Perineal  Ureterotomy. — A  calculus  in  the  part  of  the  male  ureter  just  above 
the  bladder  is  considered  by  some  to  be  the  best  approached  through  the  Zucker- 


FiG.  414.  —  Perineal  Ureterotomy.  Patient  in  the  lithotomy  posi- 
tion. The  prostate  is  the  upper  angle  of  the  wound;  the  fascia  over 
the  seminal  vesicle  opened;  the  vesicle  and  the  vas  pulled  to  one 
side  and  ureter  hooked  up  and  incised  over  the  calculus.  (Author's 
operation.) 


654 


OPERATIONS  ON  THE  URETER 


kandl  perineal  incision  that  is  employed  for  the  removal  of  the  prostate  or 
seminal  vesicles,  as  the  abdominal  operation,  especially  when  made  through 
the  oblique  muscles,  is  liable  to  be  followed  by  hernia.  The  patient  is  placed 
in  the  lithotomy  position  and  the  incision  made  in  front  of  the  anus,  up  be- 
tween the  prostate  and  the  rectum  and  just  beyond  the  prostatic  base.  The 
ureter  is  found  just  beneath  or  to  the  inner  side  of  the  seminal  vesicle,  with 
the  vas  deferens  passing  in  front  of  it.  It  is  seized  by  a  blunt  hook,  the  sem- 
inal vesicle  and  the  vas  are  retracted,  an  incision  is  made  over  the  calculus  and 
the  stone  is  removed  from  forceps  (Fig.  414). 

Drainage  is  made  through  the  perineum,  after  which  any  urine  leaking  from 
the  wound  runs  through  the  sinus  remaining  in  this  region,   which  usually 

closes  slowly.  The 
drain  is  left  in  but  a 
few  days. 

Vaginal  Route. — 
The  lower  part  of  the 
canal  outside  of  the 
bladder  wall  is  best 
approached  in  women 
through  the  vagina. 
The  steps  of  the  opera- 
tion are  as  follows: 
Patient  in  the  gyneco- 
logical position.  The 
ureter  should  be  cathe- 
terized.  A  transverse 
incision  is  made  in  the 
vagina  from  the  cor- 
responding side  of  the 
cervix  uteri,  or  a  verti- 
cal one  just  beside  it. 
After  the  vaginal  wall 
has  been  cut  through, 
the  catheter  and  calcu- 
lus can  usually  be  felt 
by  the  finger  tip  intro- 
duced through  the  .in- 
cision. If  not,  the  tis- 
sues should  be  pushed 
down  by  suprapubic  pressure  with  the  other  hand.  The  ureter  should  now  be 
caught  by  a  blunt  hook  and  pulled  down,  and  a  traction  suture  passed  about 
it  by  means  of  a  blunt-pointed  needle,  so  as  not  to  wound  the  uterine  artery. 


Fig.  415. — Patient  in  the  Gynecological  Position.  An  in- 
cision is  seen  in  the  vaginal  wall  by  the  side  of  the  cervix  uteri. 
The  ureter  has  been  hooked  up  and  incised  over  the  calculus. 


UEETEROTOMY 


655 


I 


The  ureter  should  then  be  steadied  and  a  longitudina*!  incision  made  in  it 
over  the  stone  (Fig.  415).  The  calculus  should  then  be  removed  with  forceps, 
and  the  catheter  pushed  through  the  canal  up  to  the  renal  pelvis  in  case  this 
could  not  be  done  at  the  beginning  of  the  operation.  The  ureteral  wall  should 
then  be  closed  by  sutures  and  a  drain  placed  close  to  the  vaginal  incision.  The 
postoperative  treatment  is  the 
same  as  that  already  de- 
scribed. 

Vesico-uretero-lithotomy. 
— Vesico-uretero-lithotomy  is 
the  operation  for  removing 
a  calculus  from  the  portion 
of  the  ureter  passing  through 
the  oladder  wall.  This  part 
of  the  canal  is  about  three 
quarters  of  an  inch  in  length 
and  is  best  apiDroached  by 
the  bladder  route. 

The  steps  of  the  opera- 
tion are  as  follows :  Tren- 
delenburg position.  Supra- 
pubic cystotomy.  Pass  a 
fine-grooved  probe  into  the 
ureter  from  the  bladder ;  in- 
cise the  ureter  up  to  the 
stone  (Fig.  416).  Insert 
the  blades  of  a  very  thin 
pair  of  forceps,  grasp  the  calculus  and  withdraw  it.  Sometimes  it  is  easier  to 
do  this  with  a  very  small  curette,  as  in  removing  urethral  calculi.  The  removal 
of  the  stone  is  sometimes  facilitated  by  counterpressure  with  the  finger  in  the 
rectum. 

Complications. — When  a  stricture  is  situated  below  a  stone  in  any  part  of 
the  canal,  this  should  be  severed  longitudinally  after  the  calculus  has  been 
removed,  as  otherwise  the  ureteral  incision  might  result  in  a  fistula.  This  can 
easily  be  done  in  the  upper  part  of  the  ureter,  but  sometimes  in  the  lower  part 
of  the  canal  it  is  necessary  to  cut  the  stricture  with  a  urethrotome  (internal 
ureterotomy). 

Uketekotomy  for  Stricture 

Technique  of  External  Ureterotomy  for  Stricture. — Stricture  of  the  ure- 
ter usually  occurs  near  the  upper  end  of  the  canal,  that  is,  near  the  kidney, 
although  it  may  occur  in  any  part  of  it.     The  incision  in  the  abdominal  wall 


Fig.  416. —  Patient  in  the  Trendelenburg  Position 
WITH  THE  Bladder  Opened  Suprapubically.  The  ureter 
and  the  part  of  the  bladder  wall  through  which  it  passes 
have  been  cut  through  and  the  stone  is  clearly  seen. 


656 


OPERATIONS  OX  THE  URETER 


depends  on  tlie  locality  of  the  narrowing  and  is  tlii'ref(jre  made  ciihcr  in  the 
lumbar  or  the  iliac  regions. 

The  ureter  is  first  catlieterized  with  a  No.  6  French  catheter,  which  enables 
the  operator  to  find  the  stricture,  as  the  catheter  stops  at  this  point.  It  can 
also  be  estimated  by  the  distance  that  it  passes  up  after  the  distal  end  has  en- 
tered the  mouth  of  the  nreter.  The  ureter  is  found  by  palpation  just  below 
the  lower  pole  of  the  kidney  when  the  stricture  is  high  uj) ;  over  the  bifurcation 

of  the  iliac  vessels  when  it  occurs  in  its  middle  por- 
tion; or  between  this  bifurcation  and  the  bladder 
in  the  true  pelvis  and  consequently  in  the  latter 
two  instances  the  inguinal  incision  or  the  incision 
through  the  rectus  abdominis  is  made. 

After  the  stricture  has  been  exposed,  a  ureteral 
clamp  is  placed  above  the  narrowing,  and  the  sur- 
rounding tissues  are  walled  off  with  gauze ;  after 
wdiich  a  longitudinal  incision  is  made  through  the 
stricture  in  the  wall  of  the  canal.  The  ureteral 
catheter  is  then  pushed  through  the  strictured  por- 
tion and  the  sutures  are  passed  through  the  ureteral 
wall  longitudinally. 

rive  sutures  are  usually  employed,  which  go 
through  all  the  layers  of  the  wall,  except  the  mucous 
membrane.  The  first  suture  is  inserted  just  above 
the  upper  ajigle  of  the  incision  and  comes  out  just 
below  the  low^er  angle.  Two  more  sutures  are  then 
passed  through  the  walls  on  either  side.  The  su- 
tures are  then  ligated,  which  makes  the  line  of  union 
transverse  and  the  strictured  portion  consequently 
wider  than  before  (Fig.  417). 
A  cigarette  drain  or  rubber  tube  is  then  inserted  down  to  the  point  of  opera- 
tion, and  the  ureter  and  the  abdominal  w^all  shoidd  be  closed  up  to  this  drain. 
This  is  withdrawn  on  the  third  day.  The  ureteral  catheters,  if  employed,  should 
be  retained  for  two  weeks.  The  kidney  pelvis  is  washed  out  once  a  day 
with  a  solution  of  1 :  2,000  solution  of  silver  nitrate,  or  1 :  500  solution  of  pro- 
targol.  The  skin  sutures  are  removed  at  the  end  of  a  week.  Some  operators 
do  not  consider  it  necessary  to  retain  the  ureteral  catheter  after  operating,  a? 
the  strictured  part  of  the  urethra  is  so  much  enlarged  by  the  operation. 


Fig.  417. — Ureterotomy  for 
Stricture.  (1)  Showing  the 
stricture  incised  longitudinally 
and  the  manner  of  passing  the 
sutures,  one  from  the  upper  to 
the  lower  angle  of  the  wound 
and  two  on  each  side,  maldng 
five  in  all.  (2)  Showing  the 
sutures  ligated,  making  the 
union  transverse  and  the  cali- 
ber of  the  canal  consequently 
wider.     (After  Albarran.) 


URETERORRHAPHY 

Ureterorrhaphy  is  an  operation  for  repairing  partial  wounds  of  the  ureter 
occurring  during  operations. 


UKETEROKKIIAPHY  657 

Partial  or  incomplete  ureteral  wounds  are  those  that  do  not  include  the 
entire  circumference  of  the  duct.  When  the  injury  has  divided  the  ureter  into 
two  ])ieces,  one  connected  with  the  Lhidder  and  the  other  with  tlio  ki(hiej,  it 
is  called  a  complete  wound  and  the  operation  consists  in  suturing-  together  the 
two  ends  of  the  ureter,  to  which  the  name  uretero-ureteral  anastomosis  or  ure- 
tero-ureterostomy  has  been  given. 

Wounds  of  the  ureter  are  for  the  most  part  accidental,  occurring  usually 
during  vaginal  and  suprapubic  hysterectomies  for  malignant  growths,  although 
sometimes  the  surgeon  deliberately  cuts  through  the  ureter  in  the  removal  of 
a  tumor.  It  is  sometimes  cut  through  higher  up  in  freeing  adhesions  and  in 
removing  the  adnexa.  Sometimes  the  ureter  is  displaced  forward  by  a  fibroma 
in  front  of  the  uterus  and  is  therefore  subjected  to  injury.  The  ureters  are 
occasionally,  although  much  less  frequently,  injured  through  other  than  oper- 
ative accidents. 

In  the  case  of  longitudinal  wounds  of  the  ureter,  their  edges  tend  to  remain 
in  contact ;  whereas  in  oblique  or  transverse  wounds,  in  which  the  ureter  is  not 
completely  divided,  the  wound  gaps  and  is  oval. 

When  the  ends  are  completely  separated,  they  can  easily  be  brought  together 
again,  except  when  too  much  of  the  ureter  has  been  injured  or  removed  or  when 
the  operator  is  not  able  to  find  the  injured  segments. 

Every  wound  of  a  ureter,  complete  or  incomplete,  not  sutured,  may  form  a 
fistula  which  later  either  heals  spontaneously  or  persists ;  consequently  a  cica- 
tricial stricture  may  also  result,  complicated  by  renal  retention  and  uretero-renal 
infection.  The  fistula  may  open  into  the  vagina,  or  through  the  abdominal  wall. 
The  wound  in  the  ureter  may  be  surrounded  by  a  mass  of  inflammatory  tissue. 
Above  the  fistula  the  ureter  is  dilated.  The  part  of  the  ureter  between  the  fis- 
tula and  the  bladder  is  usually  thickened  but  permeable.  A  cicatricial  stricture 
may  also  result,  complicated  by  renal  retention  and  uretero-renal  infection. 
The  greatest  danger  in  wounding  the  ureter  during  a  laparotomy  is  through 
infection  of  the  peritoneal  cavity  by  septic  urine  and  a  consequent  septic 
peritonitis. 

Technique  of  Ureterorrhaphy. — First,  free  the  ureter  and  compress  it  to 
prevent  urinary  leakage.  It  can  be  compressed  above  the  injury  with  a  piece 
of  gauze,  tape  or  ureteral  clamp.  The  ureteral  wound  having  been  exposed, 
it  can  be  united  by  longitudinal,  transverse  or  oblique  interrupted  sutures 
of  fine  chromic  gut,  care  being  taken  not  to  perforate  its  mucous  wall. 

The  operation  for  the  union  of  a  longitudinal  tear  is  that  of  ureterotomy 
for  stricture  (Fig.  417).  The  operation  for  a  transverse  wound  necessitates  the 
making  of  two  incisions  a  sixth  of  an  inch  long,  one  upward  and  one  downward 
from  the  middle  of  the  transverse  wound  and  then  proceeding  as  follows :  The 
first  suture  should  be  from  just  above  the  upper  angle  of  the  longitudinal  cut 
to  just  below  the  lower  angle.     The  second  suture  should  be  introduced  through 


658 


OPERATIONS  ON  THK  UHETER 


either  side  of  the  longitudinal  cnt  just  above  the  angle  that  it  forms  with  the 
transverse  wonnd  and  conies  out  in  the  corresponding  position  helow.  Another 
suture  should  then  he  placed  through  the  transverse  wound  on  either  side  near 
its  ends  (Fig.  4ls,  A  ;ind  B).     This  also  results  in  a  transverse  line  of  sutures 

making  the  ureter  wider  than  before 

at  this  point. 


A  B 

Fig.  418. — Ureterorrhapht.  {A)  A  transverse 
tear.  A  longitudinal  incision  one  sixth  of  an 
inch  in  length  extends  upward  and  downward 
from  its  middle  point.  {B)  Five  sutures  are 
then  passed:  one  from  the  upper  to  the  lower 
angle;  one  through  either  side  of  the  longitudi- 
nal cut  just  above  the  angle  it  forms  with  the 
transverse  wound,  and  one  other  on  each  side 
of  the  transverse  incision  near  its  end.  When 
Hgated,  a  transverse  wound  results  larger 
than  the  remainder  of  the  canal.  (After  Al- 
barran.) 


.4  B 

Fig.  419. — Poggi'.s  Operation.  .4,  The  manner 
of  placing  the  sutures  prior  to  invaginating  the 
upper  segment  into  the  lower.  B,  The  anas- 
tomosis completed  and  the  sutures  in  place. 


URETERO-URETEROSTOMY 

(End-io-end  Anastomosis) 

The  operation  of  uretero-nreterostomy  is  performed  when  tlie  ureter  has 
been  completely  severed  in  abdominal  operations.  The  operations  are  the 
Poggi,  the  Van  Hook  and  the  Bovee.  Of  these,  the  Poggi  operation  appeals 
to  me  the  most  (Fig.  -ilO). 

The  Poggi  Operation. — The  ends  are  approximated.  Both  ends  are  cut 
transversely  in  case  they  are  irregular.  The  distal  end  is  stretched  and  then 
a  slit  is  made  on  its  anterior  surface  one  sixth  of  an  inch  long,  to  enlarge  it 
sufficiently  to  allow  the  upper  end  to  enter  it.  A  plain  catgut  suture  is  passed 
one  eighth  of  an  inch  from  the  cut  surface  through  the  posterior  wall  of  the 
upper  segment  from  within  outward,  resembling  an  inverted  "  U."  The  ends 
are  then  brought  down  and  through  the  posterior  wall  of  the  lower  segment, 
from  within  outward,  at  a  corresponding  distance  from  the  cut  surface ;  then 
the  upper  segment  is  pulled  into  the  lower  segment  and  the  ends  of  the  sutures 
tied  behind,  after  which  the  sides  are  sutured  together  with  Xo,  1  chromic  gut. 
The   anterior  slit  is   also  sewed  together,   including  the   invaginated  segment, 


URETEROSTOMY 


659 


with  two  sutures  of  the  same  size.     None  of  these  holding  sutures  go  through 
the  mucous  membrane,  as  is  the  case  with  the  plain  gut  suture. 

Van  Hook's  Method. — In  this  procedure,  which  involves  a  shortening  of 
the  duct,  the  i3eri})heral  end  of  the  ureter  is  ligated  near  the  line  of  division 
and  a  longitudinal  incision  is  then  made 
below  the  ligature.  The  incision  should 
be  twice  as  long  as  the  diameter  of  the 
ureter.  The  central  end  is  slit  for  five  to 
six  millimeters,  to  keep  it  gaping,  and  a 
"  U  "  suture  is  applied,  passing  from  with- 
in outward.  The  two  ends  of  this  thread 
enter  the  peripheral  stump  of  the  ureter 
through  the  wound,  passing  through  the 
walls,  from  within  outward,  below  the  lat- 
eral slit.  The  central  fragment  of  the 
ureter  is  invaginated  into  the  perij)heral 
fragment  by  pulling  it  into  the  opening 
and  tying  the  two  ends  of  the  suture  on 
the  outside  wall.  The  anastomosis  is  com- 
pleted by  suturing  the  longitudinal  wound 
of  the  lower  segment  on  each  side  of  the 
graft  (Fig.  420). 

Bovee's  Method. — This  procedure  was  devised  with  the  object  of  preventing 
the  occurrence  of  constriction,  which  is  apt  to  follow  after  anastomosis  by  the  end- 

in-end,  the  end-in-side  and  the 
transverse  end-to-end  method 
of  ureteral  union  (Fig.  421). 
In  Bovee's  oblique  end-to-end 
junction,    the    divided    ends 
of    the    ureter    are    trimmed 
obliquely,     brought    together 
and  united  by  two  rows  of  in- 
terrupted   sutures   not    pene- 
trating the  mucosa. 
After  these  operations,  the  peritoneum  is  sutured  and  a  drain  is  inserted 
through  the  abdominal  wall  on  a  level  with  the  suture,  after  which  the  abdom- 
inal wound  is  closed  up  to  the  drain. 


Fig.  420. — Van  Hook's 
Operation.  A,  The 
position  of  the  trac- 
tion suture  in  the  prox- 
imal end  of  the  ureter. 
B,  The  longitudinal 
incision  in  the  distal 
end  into  which  the 
proximal  end  is  to  be 
invaginated. 


Fig.  421. — Bovee's  Method  of  End-to-end  Anastomosis  by 
Approximating  Obliquely  Cut  Ends  without  Invagi- 
nating  Them. 


URETEROSTOMY 

Ureterostomy  is  the  name  given  to  the  grafting  of  the  proximal  end  of  the 
ureter  into  the  skin. 


660  OPERATIOIs^S    OX    THE    URETER 

The  grafting  of  the  proximal  segment  of  a  ureter  into  the  skin  after  an  in- 
jury is  the  simplest  method  of  establishing  the  elimination  of  urine  from  the 
corresponding  organ.  This  operation  is  a  very  simple  one,  but  the  results 
have  been  far  from  satisfactory  and  most  of  the  patients  have  survived  the 
operation  but  a  short  time.  I  consequently  cannot  recommend  the  operation 
and  think  that  a  nephrostomy  Avitli  direct  drainage  from  the  renal  pelvis  into 
the  loin,  or  even  a  nephrectomy,  promises  better  results.  The  patients  usually 
die  of  jDyelo-nepliritis  or  pyonephrosis,  due  to  renal  infection  after  this 
procedure. 

"When  an  injury  is  due  to  an  accident  during  a  laparotomy,  some  ligate  the 
distal  fragment  and  bring  the  proximal  fragment  into  the  lower  angle  of  the 
abdominal  incision.  This  operation  is,  however,  best  ajoplied  to  cases  in  which 
the  external  opening  can  be  made  in  the  lumbar  region.  The  ureter,  having 
been  compressed  above  the  seat  of  injury,  is  freed  from  its  normal  position  and 
the  end  is  brought  into  the  lower  segment  of  the  wound,  as  has  already  been 
mentioned.  In  fixino;  the  ureter,  we  must  allow  for  a  sufficient  lena'th  of  the 
duct  to  drain  the  kidney  and  take  care  not  to  form  a  loop  of  sufficient  length  to 
have  it  sag  and  retain  urine. 

Two  small  incisions,  a  quarter  of  an  inch  long,  are  made  opposite  one  an- 
other in  the  end  of  the  canal  to  fit  the  skin  opening  better.  The  ureter  end  is 
then  made  fast  to  the  skin  by  any  suture  not  going  through  the  entire  ure- 
teral wall. 

A  ureteral  catheter  should  be  left  in  for  some  days.  The  lumbar  wound  is 
closed  as  usuaL     The  operation  is  unsatisfactory  and  I  do  not  recommend  it. 

URETERO-CYSTOTOMY 

Uretero-cystotomy  consists  in  operating  upon  the  ureter  for  injuries  near 
the  bladder,  which  usually  occur  in  women  during  a  hysterectomy  operation, 
and  making  an  anastomosis  of  this  canal  with  the  bladder.  It  is  performed 
by  the  transperitoneal,  extraperitoneal  and  transvesical  routes. 

Transperitoneal  Method. — A  median  laparotomy  is  performed  (Fig.  -113 ). 
The  lower  segment  of  the  ureter  is  ligated  and  the  end  cauterized.  It  is  some- 
times difficult  to  find  the  upper  segment  that  w^e  intend  implanting  in  the  blad- 
der, as  it  retracts  ;  in  which  case  the  iliac  vessels  should  be  cut  down  upon  and  the 
ureter  found  and  freed  down  as  far  as  its  end.  Two  slits,  one  sixth  of  an  inch 
long,  are  then  made  on  either  side  in  the  end  of  the  proximal  portion  of  the  canal 
and  an  inverted  "  U  "  suture  is  passed  through  the  ureter  on  either  side,  the 
vault  of  the  inverted  "  U  "  being  on  the  inside  of  the  ureter.  The  ends  of  these 
sutures  are  threaded  on  thin  curved  needles.  A  diagonal  slit  is  now  made  on 
the  posterior  lateral  w^all  of  the  bladder  and  a  ureteral  catheter  is  passed  up 
from  below  and  out  of  the  bladder  incision  into  the  ureter.     The  ends  of  the 


URETEKO-CYSTOTO:^^^ 


661 


"  U  "  sutures  are  passed  tliroui;li  the  l)la(l(ler  wall  on  the  two  sides  of  the  in- 
cision, from  within  outward,  and  the  end  of  the  ureter  is  pulled  into  the 
bladder.  The  ends  of  the  sutures  are  then,  pulled  taut  and  tied  on  the  out- 
side of  the  vesical  wall.  In  this  way,  the  opening  of  the  ureter  in  the  bladder 
is  held  well  open.  The  bladder  is  then  closed  up  to  the  ureter  on  either  side 
with  fine  silk  sutures,  care  being  taken  not  to  make  pressure  upon  it  sufficient 

to  cause  obstruction  of  the  duct  (Fig.  422).  The 
ureteral  catheter  is  retained  in  the  canal  and 
the  urethral  catheter  in  the  bladder.  Great  care 
must  be  taken  to  keep  the  operative  field  well 
walled    off    to    avoid    urinarv    leakaue.     The    ab- 


A  B 

Fig.  422. — Transperitoneal  Method  in  Uretero-cystotomt.  A,  The  manner  of  passing  the  su- 
tures through  the  ureter  and  bladder.  B,  The  manner  of  tying  the  sutures  on  the  outside  of  the 
bladder  wall. 

dominal  wall  should  then  be  closed.  Drainage  can  be  established  througb  the 
vagina  by  passing  pointed  scissors  up  to  the  side  of  the  cervix  uteri  and  through 
the  vault  of  the  vagina  on  that  side  and  inserting  a  tube,  cigarette  drain  or  wick. 
The  flat  dorsal  or  the  dorsal  reclining  ]Dosition  is  recommended  after  operation. 

Various  other  methods  of  implantation  are  used  by  means  of  buttons  and 
difl^erent  devices.  The  simple  method  of  stabbing  a  hole  in  the  bladder  from  the 
outside  with  a  scalpel,  pushing  the  end  of  the  ureter  into  it  with  thumb  force])s 
and  suturing  the  outer  wall  of  the  ureter  to  that  of  the  bladder  on  either  side, 
has  been  successful  in  many  cases  without  the  use  of  a  ureteral  catheter. 

Extraperitoneal  Uretero-cystotomy. — This  route  is  a  difficult  one  to  follow- 
out  in  women,  as  the  ureter  is  usually  cut  during  a  hysterectomy  in  the  region 
of  its  greatest  exposure,  which  is  just  behind  the  uterine  vessels ;  after  which 
it  retracts.  It  would  therefore  be  necessary  either  to  close  the  peritoneum 
and  then  separate  the  tissues  extraperitoneally  until  the  ureter  is  found ;  or 
else  to  make  another  incision  in  the  side  of  the  abdomen,  which  would  weaken 
the  wall  considerably  and  predispose  to  hernia.  After  an  operation  on  the 
udnexa  and  especially  after  a  hysterectomy,  the  transperitoneal  route  is  easier. 
In  men,  injuries  or  any  other  conditions  requiring  an  extraperitoneal  uretero- 


662  OPERATIONS  ON  THE  URETER 

cystotomy  are  very  rare.  It  appears,  therefore,  that  the  transperitoneal  nre- 
tero-cystotomy  is  the  better  (Fig,  413). 

Uretero-vaginal  Anastomosis. — A  nrotero-vaginal  anastomosis  is  not  recom- 
mended, as  it  is  usually  followed  by  hydronephrosis.  The  best  result  that  can 
be  obtained  by  this  operation  is  a  uretero-vaginal  fistula,  which  is  not  desirable. 

Transvesical  Uretero-cystotomy. — Transvesical  uretero-cystotomy  is  also 
not  recommended.  This  operation  consists  in  making  a  suprapubic  cystotomy, 
inserting  a  grooved  director  into  the  ureter,  grasping  and  pulling  the  ureter 
into  the  bladder  and  incising  and  separating  its  ends,  as  in  the  case  of  the  trans- 
peritoneal operation.  After  this,  the  ends  should  be  sewed  to  the  muscular 
wall  of  the  bladder  from  its  inside,  or  else  the  peritoneum  should  be  opened 
above  the  bladder  and  the  suture  passed  through  the  bladder  Avail  from  the 
inside  and  ligated  on  its  outside  through  the  peritoneal  incision.  In  this  opera- 
tion, there  is  great  danger  of  infection  of  the  peritoneum  by  the  urine  and  it 
cannot  be  recommended. 

URETERO-INTESTINAL   ANASTOMOSIS 

(Grafting  of  Ureters  to  Intestine') 

This  operation  is  performed : 

1.  For  accidental  wounds  of  the  ureter,  when  neither  uretero-ureteral  anas- 
tomosis nor  vesical  grafting  appear  feasible. 

2.  For  the  cure  of  ureteral  fistula.     (Chaput.) 

3.  After  total  cystectomy.     (Kiister.) 

4.  In  exstroj^hy  of  the  bladder.      (Simon.) 

Ureteral  grafting  into  the  intestine  is  a  serious  operation,  with  a  very  high 
immediate  and  remote  mortality,  which  may  be  estimated  as  thirty-five  to  forty 
per  cent.  The  high  operative  mortality  is  due  to  local  infection  about  the  anas- 
tomosis giving  rise  to  abscess,  fistula  and  stricture  in  cases  immediately  after 
the  operation  or  to  a  renal  infection  at  a  later  date. 

Selection  of  Intestinal  Segment. — The  rectum,  sigmoid  fiexure,  cecum  and 
ascending  and  descending  colon,  have  been  principally  used  for  this  purpose. 

The  operation  is  usually  performed  by  the  intraperitoneal  route,  although 
occasionally  the  ureter  has  been  grafted  to  the  colon  or  rectum  by  the  extra- 
peritoneal route. 

Uretero-colostomy. — This  operation  can  be  j^ei'formed  by  either  the  extra- 
or  intraperitoneal  route.     The  stejDs  are : 

Expose  the  ureter ;  free  the  ureter ;  suture  the  ureter  to  the  colon. 

The  first  two  steps  have  been  described  under  the  extra-  and  intraperitoneal 
incisions  in  ureteral  surgery  (Figs.  409  and  413). 

Operative  Technique. — The  ureter  is  freed  and  brought  in  contact  with 
the  portion  of  the  colon  chosen  for  the  seat  of  the  anastomosis.     The  intestinal 


URETERECTOMY 


663 


Avail  is  freshened  and  nnccjvered  al  this  jj(jinl.  The  ])arietal  peritoneum  is 
incised  from  the  I'ciiidn  of  the  nreter  to  that  of  the  (-(jlon  and  the  two  sides 
dissected  l)ack.  The  iirder  is  placed  in  this  space  and  hronght  in  contact  with 
the  intestine. 

At  one  and  one  half  centimeters  from  its  cut  end,  a  suture  is  passed  through 
the  outer  laver  of  the  \ireteral  wall,  fixing  it  to  the  lateral  wall  of  the  colon, 
after  which  the  free  edges  of  the  peritoneum  are  brought  over  the  ureter  and 
the  wall  of  the  colon  is  also  sewed  over  it  in  such  a  way  as  to  bury  it. 

On  the  anterior  surface  of  the  colon  a  quadrilateral  flap  is  made  on  either 
side  of  and  across  the  longi- 
tudinal band  of  the  gut, 
two  centimeters  long  and 
one  centimeter  wide,  ex- 
tending through  the  serous 
and  muscular  coat. 

The  incision  of  the  flap 
is  made  on  either  side  and 
below  but  not  above,  which 
part  is  left  intact. 

The  flap  is  then  re- 
flected upward.  The  mu- 
cous coat  of  the  gut  is  then 
cut  through  in  the  same 
lines  of  incision  and  folded  upon  itself  and  attached  by  sutures  at  its  upper 
edge  in  such  a  way  as  to  form  a  mucous  valve  (Fig.  423,  A). 

The  end  of  the  ureter  is  placed  on  the  front  of  the  mucous  surface  of  the 
valve  and  fastened  there  by  suture  (Fig,  423,  B). 

•The  reflected  sero-muscular  flap  is  then  brought  down  over  the  mucous 
valve  and  the  end  of  the  ureter,  and  is  sewed  to  the  edges  of  the  wound  in  the 
intestine  below  and  on  its  sides,  thus  burying  the  ureter  (Fig.  423,  C). 

It  will  be  seen  that  the  ureter  then  has  an  oblique  tract  and  a  valve  at  its 
new  orifice. 

URETERECTOMY 

Excision  of  the  ureter  is  performed  in  tuberculosis  of  the  kidney  and  ureter 
and  in  suppurative  cases  in  which  the  ureter  is  involved  on  account  of  fistulas, 
strictures  and  ureteral  retention  of  urine  or  pus.  Ureterectomy  may  be  primary 
or  secondary.  In  the  first  instance,  the  ureter  is  removed  with  the  kidney  and 
in  the  second  instance  after  the  removal  of  the  organ.  It  may  be  partial  or 
total,  the  former  when  only  a  segment  is  removed  prior  to  some  anastomosis. 

Technique  of  Ureterectomy. — The  ureter  should  first  be  catheterized  from 
below  up,  or  from  above  down,  and  any  fistulas  present  should  be  curetted  and 


A 

Fig.  423. — Uretero-colostomy.  A,  The  line  of  incision  of  the 
flap  through  the  serous  and  muscular  coats  of  the  colon.  B, 
The  colon  flap  lifted  up  and  a  muscus  flap  of  the  same  size 
folded  on  itself  and  fastened  above.  The  ureter  is  seen  buried 
in  the  side  of  the  intestinal  wall  and  fastened  to  the  muscus 
flap.  C,  The  sero-muscular  flap  brought  down  in  place  and 
sutured  to  the  line  of  incision.     (Pierre  Duval.) 


664 


OPERATIONS  ON  THE  URETER 


■washed  out  with  peroxid.  A  curved  incision  is  recommended  from  the  kidney 
angle  down  along  the  erector  spintc  muscle,  past  the  anterior  superior  spine  of 
the  ilium  to  the  external  border  of  the  rectus  abdominis  muscle,  nearly  to  its 
insertion  (Fig.  424).  The  different  muscular  planes  are  then  cut  through  down 
to  the  subperitoneal  fat.  The  ureter  is  then  felt  for  in  the  lumbar  region,  where 
it  is  more  exposed ;  but  in  case  it  is  not  found  there,  it  should  be  sought  in  the 
iliac  fossa.     In  looking  for  the  ureter,  the  fingers  of  the  operator's  hand  should 


Fig.  424. — Ileo-lumbar  Incision  for  a  Complete  Xephro-ureterectomt. 
(From  Pierre  Duval.) 

gently  work  their  way  under  the  peritoneum  with  their  backs  pointing  to  the 
abdominal  Avail  while  making  traction  on  the  peritoneum  with  the  other  hand. 
The  ureter  is  usually  quite  easily  discovered  on  account  of  the  hard  feel  trans- 
mitted to  it  by  the  contained  catheter.  Sometimes,  however,  the  ureteral  cathe- 
ter is  stopped  in  its  course  by  tuberculous  thickenings  of  the  ureter,  by  strictures 
and  by  fistulous  tracts  causing  a  narrowing  of  the  canal  below  them.  In  that 
case,  the  ureter  should  be  cut  down  upon  at  the  highest  point  to  which  the 
catheter  has  passed  and  the  work  can  be  begun  at  this  point.  In  any  case,  after 
the  ureter  has  been  found,  a  traction  suture  should  be  passed  about  it  and  it 
should  be  separated  down  to  the  point  at  which  it  joins  the  bladder.  A  ligature 
is  then  placed  around  the  ureter,  three  quarters  of  an  inch  from  the  vesical 
wall,  and  the  ureter  is  seized  and  lifted  up,  a  gauze  pad  is  placed  beneath  the 
ureter  to  protect  the  surrounding  tissues  and  the  duct  is  cut  through  with  scis- 
sors ;  after  this  the  lumen  of  the  stump  is  cauterized  by  carbolic  acid  or  a  Paque- 
lin  cautery.  The  ujjper  segment  of  the  ureter  should  then  be  dissected  out. 
In  case  there  are  adhesions  along  the  tract,  it  may  be  necessary  to  dissect  the 
ureter  out  with  scissors ;  whereas,  in  the  case  of  a  fistula,  it  may  be  necessary 
to  approach  it  from  above  as  well  as  from  below.  The  fistulous  tract  leading 
from  the  ureter  must  be  curetted  afterwards  to  remove  all  the  granulations,  in 
order  that  it  may  heal.  The  entire  wound  should  be  closed  or  a  sufficient  space 
can  be  left  above  or  below  to  allow  the  passing  of  a  gauze  wick  for  drainage,  if 
there  is  an  area  of  periureteral  suppuration  present. 


NEPHRO-URETERECTOMY 


665 


NEPHRO-URETERECTOMY 

Tn  case  the  kidney  and  the  nreter  are  removed  at  the  same  time,  the  kidney 
is  first  freed  and  is  held  as  a  tractor  while  the  ureter  is  stripped  down  to  the 
hladder.  In  this  case,  the  patient  lies,  from  the  beginning  of  the  operation,  on 
the  healthy  side  nntil  after  the  kidney  has  been  liberated,  when  he  should  be 
turned,  on  his  back  and  the  operation  continued  either  flat  or  partially  Tren- 


j^.^^ 


Fig.  425. — Nephro-tjreterectomy.  Transverse  incision  in  the  median  line.  The  kidney  removed 
and  hanging.  The  fingers  of  one  hand  are  in  the  incision  and  free  the  ureter  down  to  the  posterior 
surface  of  the  broad  ligament,  where  it  is  ligated  and  cut  away.  (From  Kelly's  "Operative 
Gynecology.") 


delenburg  and  then  perhaps  more  fully  Trendelenburg,  as  the  bladder  is  ap- 
proached. A  space  for  drainage  should  be  left  above  and  below,  and  it  should 
be  closed  in  the  middle. 

This  operation  is  sometimes  done  from  below  upward  when  there  is  a  large 
stone,  stricture  or  impassable  tuberculous  thickening  in  the  lower  ureter  near 


ggg  OPERATIONS  ON  THE  URETER 

the  bladder.     The  only  time  I  have  performed  this  operation  ^vas  in  the  case 
of  a  ureteral  stricture  low  down  in  the  ureter  with  a  nonfunctionating  kidney 

above  it.  i-      i       • 

In  case  the  kidney  has  already  been  removed  and  there  are  no  hstulas  m 


L5it       lac. 


i 


y 


Fig  426.-NEPHRO-URETERECTOMY.  Shows  the  operator's  two  fingers  do^ui  o  the  vag  "al  ^^^^^^^ 
side  of  the  cervix  uteri  and  the  fingers  of  an  assistant  pressing  against  them  t^-'^^f  Jj  \;j^";^ 
The  Jharp-pointed  blades  of  a  pair  of  scissors  are  then  thrust  up  through  the  vagmal  wall  between 
the  finirs  'The  stump  of  the'ureter  is  then  pushed  down  through  the  incision  and  again  hgated 
farther°down  and  cut  away.     (From  KeUy's  "Operative  Gynecology.   ) 


NEPHRO-UilETERECTOMY  667 

tlie  loin  and  the  pathological  conditions  arc  in  the  iliac  portion  of  the  ureter, 
the  incision  through  the  abdomen  anteriorly  may  suffice  for  removing  the  re- 
maining ureter.  In  other  cases,  there  can  be  two  incisions,  one  in  tlio  loin  and 
one  in  the  groin,  with  a  bridge  of  tissue  between  the  two ;  in  which  case,  the 
kidney  has  to  be  removed  through  a  vertical  lumbar  incision  and  the  entire  ure- 
ter through  the  groin.  In  women,  the  Howard  Kelly  method  of  removing  the 
kidney  through  a  transverse  incision  and  the  ureter  through  the  vagina  is  both 
practicable  and  instructive  (Figs.  425,  426),  The  kidney  is  freed,  its  vascular 
pedicle  ligated  and  it  is  delivered  through  the  transverse  incision. 


(2) 


INDEX 


Abdomen,  examination  of,  i.  308. 
Abdominal  supports,  i.  415. 
Abnormalities  of  kidneys,  i.  40. 
Abscess   of   kidney,   i.   473. 

of  penis,  ii.  526. 

of  prostate,  ii.  199. 

perinephritic,  i.   466. 
Accelerator  urinae,  i.  26,  27. 
Acetone  in  urine,  i.  86. 
Actinomyces,  i.   115. 
Actuarius,  i.  2. 
Acuniinatse,   ii.  537. 
Adenoma,   malignant,   i.   482. 

of   kidney,   i.   481. 

of  penis,  ii.  528. 
Adenitis,  inguinal.     See  Bubo. 
Age  of  patients  in  diagnosis,  i.  297. 
Agurin,   i.   436. 
Air  cystoscopes,  i.   203. 
Aix  la  Chapelle,  ii.  707. 
Albumin    in   urine,    i.   76. 

discovery  of,  i.  3. 
Albumose  in  urine    i.  78. 
Albuminuria,   Bence-Jones,   i.   78. 
Albarran,  i.  5. 

cystoscope  of,  i.  202. 

operation  of,  for  uronephrosis,   i.   617. 
Albargin,   ii.   379. 
Alcock's   canal,  i.   25,   31. 
Alcohol,  nephritics  and,   i.   434. 
Alcoholic   beverages,   i.    326. 
Alcoholic  coma,   uremia   and,   i.  448,   450. 
Alcoholic  excesses,  urethritis  and,  ii.  352. 
Alimentary   glycosuria,   i.   365. 
Alkaline  carbonated  waters,   i.   339. 

muriated  waters,  i.   339. 

saline  mineral  waters,  i.  340. 
Allison  table,  i.   146. 
Alopecia,  luetic,  ii.  688. 
Ammonia,  uremia  and,  i.  452. 
Ammonium  carbonate,  uremia  and,  i.  440. 
Amyloid  casts,  i.    108. 


Amyloid  kidney,  i.  437. 

diagnosis  of,  i.  439. 

etiology  of,  i.  437. 

pathology  of,  i.  438. 

pyocyaneus    bacillus   and,   i.    438. 

symptoms  of,  i.  438. 

treatment  r>f,  i.  439. 
Ancient  urology,  i.   1. 
Andrews,   Wyllis,   hydrocele   operation  of,    ii. 

582. 
Anesthesia,  i.  7. 

combined  method  of,  i.  352. 

in  urology,  i.  350. 
Angioma   of  kidney,  i.   481. 
Animal   inoculation,   i.   113. 
Annular  kidney,  i.  385. 
Anorchism,  i.  586. 
Antiseptic  method  of  Lister,  i.  6. 
Antiseptic  solutions  for  cystitis,  ii.  46. 

for  gonorrhea,  ii.  378. 
Antispasmodic  mixture  for  urethritis,  ii.  390, 
Anuria,   calculous,  i.  522. 

diagnosis   of,   i.   275. 

etiology  of,  i.  273. 

kidney  injury  and,   i.   393. 

retention    of    urine    and,    differentiated,    i. 
259. 

symptoms   of,   i.   275. 

treatment  of,  i.  276. 
Anus,  imperforate,  ii.   312. 
Apenta  water   in  cystitis,  ii.   48. 
Apoplexy,  uremia  and,  i.  448. 
Apparatus   and   instruments,   sterilization  of, 

i.   153. 
Apparatus  recommended  for  office,  i.   130. 
Appendicitis,  bladder  enlargement  and,  ii.  2. 

nephrolithiasis  and,  i.  513. 
Appendix,   bladder    displacement    due    to,    ii. 

109. 
AppointnK  rit    form.    i.    148. 
Argentamin,  ii.   379. 
Argonin,  ii.  379. 

669 


670 


INDEX 


Argyrol,   ii.   379. 
Arsenical  preparations,  ii.  715. 
Arseno-benzol   (see  also  salvarsan),  ii.  715. 
Arteriosclerosis,    chronic    interstitial    nepliri- 

tis  and,  i.  425. 
Arthritis,  gonococcal,  ii.  51G. 
Asepsis,  i.  7. 
Aspergillus,  diabetic  balano-posthitis  and,  ii. 

541. 
Aspiration,    i.    263. 

dropsy  and,  i.  437. 

of  kidney,  1.  548,  583. 

of  urine,  ii.  253. 
Astringent  solutions  in  urethritis,  ii.  380. 
Athletic  bandage,  ii.   613. 
Atoxyl,   ii.  715. 
Ayres's  extractor,  ii.  144. 
Ayurveda  of  Sucrutu,  i.  1. 

"B.  and  B.  mixture,"  ii.   103. 

for  cystitis,  ii.  47. 
Bacteria  in  blood,  i.  135. 

in  cystitis,  ii.  35. 

mode  of  entrance  of,  into  the  urine,  i.  111. 
Bacteriological   discoveries,   i.    5. 
Bacteriological   examination  of  urine,  i.   115. 
Bacteriology  of  urine,  i.   110. 
Bacteriuria,  i.  282,   286. 
Balanitis,  ii.  538. 

gonococcal,  ii.  539-. 

secondary,  ii.  539. 

syphilitic,  ii.  539. 

treatment  of,  ii.  541. 
Balano-posthitis,   chronic,   ii.   540. 

diabetic,   ii.    540. 
Balano-preputial   sulcus,   i.  68. 
Ballottement  ,of  kidnej",  i.  371. 
Balsamies,   ii.   370. 
Balsams  in  cystitis,  ii.   46. 
Bandage,  scrotal  or  T,  ii.  611,  612. 
Barium  solution,  i.   91. 
Bartholin,  glands  of,  i.  57. 
gonorrhea  and,   ii.   513. 
Bartholinitis,   ii.  506. 
Basham's  mixture  in  cystitis,  ii.  48. 
Baths,  i.  344. 

Behavior,  general,  in  examination,  i.  306. 
"  Belladonna  and  potash  mixture,"  ii.  44. 
Bellini,  i.  2. 

Bence-Jones   albuminuria,   i.   78. 
Benique  sound,   i.    179,   180,   ii.   430. 
Benzoate   of  soda,   i.   554. 

nephritis  and,  i.  429. 
Benzoates  in  cystitis,  ii.  47. 
Bertini,  columns  of,  i.  37. 


Sevan's  operation  for  retained  testis,  ii.  590. 
Bigelow  and  lithotrity,  i.  4. 
Bigelow's  lithotrite,  ii.    135. 
Bigelow's  method  of  removing  calculi,  ii.  92. 
Bi-coude  catheters,  i.   163. 
Bike  jock  bandage,  ii.   613. 
Bile   pigment   in  urine,  i.   88. 
Bilharzia  infection  and  bladder  tumors,  ii.  59. 
Bilirubin  in  urinary  sediment,  i.  98. 
Bitter  laxative  waters,  i.  341. 
Bladder,  atony  of,  causes  of,  i.  256. 
treatment  of,  i.  265. 
cavity  of,  i.  50. 

congenital  malformations  of,  ii.  8. 
cystoscopic  appearance  of,   i.   221. 
diseases   of,  nephrolithiasis  and,  i.  512. 
distended,  i.  47. 

distention  of,  due  to  spinal  lesion,  i.   259. 
disturbances  of,  due  to  extravesical  causes, 
etiology   of,  ii.    105. 
illustrative  case  of,  ii.   111. 
symptoms  of,  ii.   105. 
varieties  of,   ii.    105. 

cancer  of  uterus,  ii.  113. 
displacement  backward,  ii.  108. 
downward,  ii.  109. 
forward,   ii.    107. 
lateral,  ii.   108. 
upward,  ii.  110. 
Fallopian  tubes,  ii.  119. 
hematocele,  ii.   119. 
hernia,  ii.  109. 
hydatid  cysts,  ii.   114. 
intestinal  interference,  ii.   120. 
lateral,  ii.   108. 
omentum,  ii.  125. 
ovarian  tumors,  ii.   113. 
pelvic  inflammations   and  adhesions, 

ii.   116. 
pelvic  tumors  and  cysts,  ii.  110. 
prolapsed  uterus,  ii.   108. 
sarcoma  of  uterus,  ii.  113. 
uterine  displacement,  ii.  105. 
vermiform  appendix,  ii.  123. 
"  edema  bullosum  "  of,   i.   226. 
enlarged,  appendicitis  and,  ii.  2. 
hydatid  cysts   and,   ii.   2. 
tuberculous  peritonitis  and,  ii.   2. 
epithelia   from,  i.   103. 
examination  of,  inspection  in,  ii.  1. 
instruments   used   for,   ii.   3. 
palpation   in,  ii.  1. 
percussion   in,   ii.  2. 
exstrophy  of,  i.  562. 
fistula   of,   ii.    16. 


INDEX 


671 


Bladder,   foreign   bodies   in,   diagnosis   of,    ii. 
81. 
etiology  of,  ii.   79. 
extraction    of,    by    lithotrite    and    cysto- 

scopc,  ii.   82. 
fistulas   and,   ii.    79. 
incrustation   of,    ii.    81. 
pathological  anatomy  of,  ii.  80. 
secondary    lesions    due    to,   ii.   81. 
symptoms  of,   ii.   81. 
treatment   of,    ii.    82. 
gangrene  of,  ii.   38. 
hematuria    and,    i.    280. 
hernia  of,  crural,  ii.  30. 
oystocele  as  a,  ii.  32. 
etiology  of,  ii.   26. 
inguinal,   ii.   27. 
perineal  and  vaginal,  ii.  31. 
urethral,  ii.  32. 
varieties   of,   ii.    26. 
incontinence  due  to  adhesions  of,  i.  271. 
inferior   vesical    fissure   in,    ii.    10. 
inflammation  of.     See   Cystitis, 
internal  sphincter  of,  i.  50. 
irrigations   of,  ii.  48. 
ligaments  of,  i.   48. 

operations  on,  Ayres's  extractor  in,  ii.  144. 
dressing  after,  ii.    102. 
hemorrhage   during,    ii.    150. 
instruments  used  in,   ii.    128. 
varieties  of: 

autoplastic    operation,    ii.    12f). 

colpocystotomy,  ii.   169. 

cystectomy,  partial,  ii.  156. 

cystoscopic,  ii.  140. 

extravesical,  ii.  129. 

foreign  bodies,  removal  of,  ii.   143. 

intravesical,  ii.   133. 

litholapaxy,  ii.   135. 

lithotrity,  ii.   133. 

Maydl's  operation,  ii.  133. 

perineal   cystotomy,  ii.   166. 

perineal  lithotomy,  ii.  167. 

prostatectomy    and    prostatotomy,     ii. 

155. 
resection  of  bladder  wall,  ii.   100. 
suprapubic   cystotomy,  ii.    144. 

technique   of,   ii.    148. 
total  extirpation,  ii.    170. 
tumors,   fulguration   of,  ii.   141. 

perineal   cystotomy  incision   and,   ii. 

168. 
removal  of,  ii.  140,  150. 
ulcers,  curetting  of.  ii.   142, 
ureteral    transplantation,    ii.    132. 


Bladder,  orifices  of,  i.  51. 

patliological    findings   in,   i.  222. 
perivesical   processes  and,   i.  220. 
phantom    (artificial),  i.  227. 
prostatic  hypertrophy  and,  ii.  230. 
relations  of,  i.  45. 

rupture  of,  uretliral  rupture  and.  ii.  332. 
ruptured,  repair  of,  ii.   144. 
sensitive,   cystoscopy  and,   i.  216. 
stone   in,   i.   224.      See   also  Vesical   Calcu- 
lus, 
structure   of,    i.    49. 
superior  vesical   fissure  in,  ii.   16. 
trabecule  of,   i.  223. 
traumatism   of,   diagnosis  of,  ii.   22. 
extraperitoneal,   ii.  24. 
intraperitoneal,   ii.   24. 
penetrating  wounds  as,   ii.    19. 
prognosis   in,  ii.   23. 
subparietal    ruptures    as,    ii.    20. 
treatment   of,  ii.  23. 
tuberculosis    of.      See    Tuberculosis    of   the 

Bladder, 
tumors  of.     See  Tumors  of  the  Bladder. 

excretion  in,  ii.   42. 
ulcer  of.     See  Ulcer  of  the  Bladder, 
vessels  and  nerves  of,  i.  51. 
washing   of,    i.    211. 
wounds    of,    extraperitoneal,    ii.    22. 
intraperitoneal,    ii.    22. 
pathological   anatomy   of,    ii.   20. 
symptoms  of,   ii.  21. 
Blasucci   catheter,   i.   261. 
Blood,   cryoscopy  of,  i.   380. 

in  relation  to  urology,   i.   132. 
Blood  oasts,  i.  106. 

Blood  cells  in  urinary  sediment,  i.  99. 
Blood  count,   i.   133. 
Blood  dust,   i.    132, 

Body-holder  on  operating  table,  i.  576. 
Boerhaeve,  i.  2. 
Boiling  of  instruments,  i.  LIS. 
Bone  sj^philis,  treatment  of,  ii.  713 
Boro-glycerid,  i.    161. 
Bottcher's  sperm  crystals,  i.   120. 
Bottini  incisor,  ii.  275. 
Bottini  operation  on  prostate,  ii.  275. 
Bowels,  care  of,  1.  336. 
Bougie  a  boule,  i.  318. 
Bougies,   ii.    430. 
Bovee's    method    in    uretero-ureterostomy,    i. 

659. 
Bozeman,   ureteral   catheterization   by,   i.   4. 
Bozzini,  i.  3. 
Bransford  Lewis  cystoseoijc,  i.  206. 


672 


IKDEX 


Braun-Buerger  cysto-urethroscope,  i.  192. 
Bread  in  diet  of  uiological  cases,  i.  324. 
Breakfast  in  urological  cases,  i.  327. 
Brenner,  1.  3,   5. 

cystoscope  of,  i.  200. 
Bright,  Richard,  i.  4. 
Bright's  disease  of  the  kidneys,  i.   418. 
Bru  injection,  ii.  382. 
Briick's  diaphanoscope,  i.  3. 
Bubo,  ii.  350,  679. 

blenorrhagia  and,  ii.  556. 

chancroid  and,  ii.   557. 

chancroidal,  ii.  557. 

chronic,   ii.   558. 

syphilis  and,  ii.  558. 

d'emble,  ii.  558. 

enucleation  and,  ii.  561. 

etiology  of,  ii.  555. 

filarial,  ii.  559. 

gummata  and,  ii.  557. 

Hodgkin's   disease  and,   ii.   558. 

inflammatory,  ii.   558. 

neoplastic  adenitis  and,  ii.  558. 

poultices   and  ice   bags   for,   ii.   560. 

spica  bandage  for,  ii.  559. 

symptoms  of,   ii.   555. 

syphilis  and,  ii.  556. 

treatment  of,  ii.  559. 
operative,  ii.  560. 

tubercular  adenitis  and,  ii.  558. 

virulent,  ii.  556. 
Buerger  cysto-urethroscope  i.  192. 
Bulbo-cavernosus,  i.   27. 
Butterfly  dressing,  ii.  367. 

Cachectic  leucocytosis,  i.   135. 
Cadet,  i.  3. 

Cselius  Aurelianus,  i.  2. 
Calcium  oxalate  in  urine,  i.  96. 
Calcium  phosphate  in  urine,  i.   97. 
Calculus,  anuria  and,  i.  522. 

cystitis  and,  ii.  53. 

cystoscopy  and,  i.  224. 

diet  for,  i.  360. 

micturition  and,   i.   241. 

of   kidney,   tuberculosis    of   kidney   and,    i. 
541. 

of  prostate,  ii.  185. 

perinephritic   abscess    and,   i.    472. 

sutures  as  nuclei  of,  ii.  161. 

Thompson's  searcher   for,   ii.    6. 

urethral.      See   Urethral    Calculus. 

vesical,  prostatic  hypertrophy  and,  ii.  245. 
Calculous   anuria,   i.   522. 
Cannula,  grooved,  ii.  457. 


Capitonnage  of  pelvis  of  kidney,  hydronephro- 
sis and,  i.  509. 
Carabana  water  in  cystitis,  ii.  48. 
Carbohydrates  in  urine,  i.   79. 
Carbonates   in  urinary   sediment,   i.   97. 

in  urine,  i.  90. 
Carcinoma  of  Covvper's  gland,   ii.   497. 

of  kidney,  i.  482. 

of   prostate,  ii.  268. 

of  testis,  diagnosis  of,  ii.  029. 
etiology  of,  ii.  627. 
pathology  of,   ii.   627. 
prognosis  of,  ii.   629. 
symptoms  of,  ii.  628. 
treatment  of,  ii.  629. 

of  uterus,    bladder    disturbance   due   to,   ii. 
113. 
Cards  for  histories,  i.  298. 
Case  history,  i.  297. 
Casper,  i.  5. 
Castration,  ii.  636. 

prostatic  atrophy  following,  ii.  267. 
Casts,   formation    of,    i.    104. 
Catheter  fever,  i.   289. 
Catheter  life,  ii.  250. 

complications   of,   ii.   256. 

epididjmiitis  and,   ii.   257. 

illustrative  cases  of,  ii.  258. 

kidney  abscess  and,  ii.  258. 

uremia  and,  ii.   258. 

urethral   fever  and,  ii.  257. 

urethritis  and,  ii.  257. 
Catheterization,  technique  of,  ii.  6. 
Catheterization  of  ureters,  i.  227. 
Catheters,  d  demeure,  i.  166. 

bi-coude,  ii.  4. 

care  of,  i.   158. 

coudg,  ii.  3. 

elbowed,  i.   165. 

en  chemise,  ii.  303,  466. 

examination  with,  ii.  5. 

eye  of,  i.  164. 

lubricant  for,   i.   263. 

Malecot's,  i.   167. 

mandrins  in,  i.  166,  ii.  4. 

metal,  i.  168,  ii.  5. 

passing  of,  i.   165. 

Pezzer's,   i.    107. 

plugged,  i.    168. 

retained,  i.  166. 

self-retaining,   i.   167. 

shape  of,  i.  162. 

soft-rubber,  ii.  5. 

straight,  1.  165. 

woven,  ii.  3,  4. 


INDEX 


673 


Cauliflower  growths,   preputial,   ii.  537. 
Cflestine  Vicliy,  ii.  48. 
Celsus,  Roman  medical  writer,  i.   1. 
Centrifuge,  i.  92. 
Centrifugation,  i.   IIG. 

Cereals  in  diet  of  urological   cases,  i.  .324. 
Cerebral  edema,  uremia  and,  i.  440. 
Chancre,     chancroid    and,    distinguished,    ii. 
677. 
phagedenic,   ii.    536. 
treatment  of,  ii.  542. 
wafer,  ii.  536. 
Chancroid,  ii.  535. 

treatment  of,  ii.  542. 
Chancroidal  urethritis,  i.  124,  ii.  408. 
Charriere  scale  of  sounds,  i.  176. 
Cheese  in  diet  of  urological  cases,  i.  326. 
Chetwood    operation    for    prostatic    hypertro- 
phy, ii.  279. 
Cheyne-Stokes    breathing    in    interstitial    ne- 
phritis, i.  307. 
in  uremia,  i.  445. 
Chlorid-free  diet,  i.  433. 
Chlorids  in   urine,   i.  89. 

uremia  and,  i.  441. 
Chloroform,  i.  350. 
Cholesterin,   i.  98. 
Chordee,  ii.  350. 

treatment  of,  ii.  374. 
"  Chordee  of  the  bladder,"  ii.  652. 
Chromogens,  i.  361. 
Chyluria,  i.  98,   282. 
Circumcision,  ii.  547. 
Civiale,  first  lithotrity  by,  i.  4. 
Clinic  and  hospital,  equipment  for,  i.   150. 
Clitoris,  i.  69. 

Coagulability  of  blood,  degree  of,  i.   135. 
Cocain,  i.   353. 
Cocain  poisoning,  i.   356. 
Coccj'geus  muscle,  i.  20. 
Coffee   and   tea,  i.   324. 
Coitus,  hypospadias  and,  ii.  315. 

preventing  infection  through,  ii.   363. 
Coley,  hydrocele  operation  of,  ii.  583. 
Cold,  nephritis  and,  i.  419. 
Cold  or  Mignon  lamp,  i.  204. 
Colic,   renal,   i.   505. 
Colles's  fascia,  i.  25. 
Colon  bacillus,  i.  114. 
in   bacteriuria,   i.   287. 
in  blood,  i.  135. 
Colpocystotomy,   ii.    169. 

vesical   calculus   and,   ii.   94. 
Compresses,  i.    142. 
Compressor  urethrse  muscle,  i.   30. 


Condom,  ii.  363. 

Conii  vasculosi,   i.   59. 

Copaiba,   skin  eruptions  from,  ii.   371. 

Copaiba  emulsion,  ii.  373. 

Corona  glandis,  i.  68. 

Corona   veneris,    ii.    682. 

Corpora  emylacea  of  prostate,  ii.   185. 

Corpora   cavernosa,   i.    67. 

bony  and  calcareous  plates  in,  ii.  553. 
gummata  of,  ii.  553. 
inflammation   of,  ii.  552. 
Corpus  spongiosum,  i.  67. 
Corpuscles   of  blood,  i.    132. 
Cotton  balls   (dressings),  i.  142. 
Cotugno,  i.  3. 
Coude   catheters,   i.    163. 
Cowperectomy,   ii.   498. 
Cowperitis,  acute,  ii.  494. 
abscess  in,  ii.  495. 
course  of,  ii.  495. 
etiology  of,  ii.  494. 
treatment  of,  ii.  496. 
chronic,  ii.  496. 

diagnosis  of,  ii.  496. 
general  hygienic  measures  in,   ii.  497. 
treatment  of,  ii.  497. 
Cowper's  glands,  i.  56. 
affections  of,  ii.  494. 

present  status  of,   ii.   498. 
cancer  of,  ii.  497. 

Cowperectomy  in,  ii.  498. 
ducts  of,  i.   196. 
Crural  hernia  of  bladder,  causes  of,  ii.   30. 
illustrative  case  of,  ii.  31. 
symptoms   of,   ii.   30. 
treatment  of,  ii.  30. 
Cryoscopy,  i.  7. 

clinical    applications    of,    i.    380. 
kidney    function    and,    i.    379. 
of  urine  and  blood,  i.  380. 
uremia  and,  i.  448. 
Cylindroids,  i.   108. 
Cystectomy,    partial,   ii.    156. 
Cystic  kidney,  tuberculosis  of  kidney  and,  i. 

544. 
Cystin,  i.  99. 
Cystitis,  acute,  ii.   38. 
treatment  of,  ii.  43. 
chronic,   ii.   39. 

exacerbations   of,   ii.  40. 
treatment  of,  ii.  45. 
classification  of,  ii.   34. 
constitutional  symptoms  of,  ii.  42. 
differentiation  of,  li.  41. 
diphtheritic,  ii.  38. 


674 


liTDEX 


Cj'stitia,  divorticulsc  in,  ii.  36. 

electricity  and,  ii.  52. 

etiology  of,   ii.  34. 

gangrene   and,   ii.    38. 

gonorrhea  and,  ii.  38. 

granular,  ii.  38. 

gynecological   troubles   and,   ii.   53. 

hematuria    and,    ii.   41. 

hemorrhagic,  i.  224,  ii.  41. 
tuberculosis  and,  ii.  99. 

interstitial,  ii.  38,  41. 

membranous,  ii.  38. 

nitrate  of  silver  irrigations  in,  ii.  50. 

nodular,    ii.    38. 

pain  in,  ii.  40. 

paretic  or  paralytic,  ii.  40. 

pathology  of,  ii.  36. 

pericystitis   and,   ii.   42. 

post-operative,  ii.  52. 

posture  and,  ii.  39. 

precipitate  urination  from,  ii.  39. 

pressure  and,  ii.  38. 

jjyuria  and,  ii.  41. 

sigmoiditis  and,  ii.  43. 

strangury  in,  ii.  41. 

symptoms  of,  ii.  38. 

tenesmus   and,  ii.   41. 

treatment  of,  ii.   43. 
local,  ii.  48. 
of  cause,   ii.    53. 

tuberculosis  and,  ii.  53. 

tuberculous,   ii.   40. 

tumor  of  bladder  and,  ii.  41. 

A'esiculitis  and,  ii.  656. 
Cystocele,  ii.  32. 
Cystogen  in  cystitis,  ii.  47. 
Cystophotographs,  ii.  89. 
Cystoscopes,  air  and  water,  compared,  i.  236. 

air  direct  observation  and  single  catheter- 
izing,  i.  203. 

Bransford  LeAvis,  i.  200. 

combined   direct   and    indirect   teaching,    i. 
207. 

combined  observation  and  double  catheteriz- 
ing,  i.  204. 

comparison  of,  i.  200. 

findings  with,  i.  218. 

Guiteras  teaching  form  of,  i.  208. 

indirect,  i.  201. 

indirect  observation  and  double  catheteriz- 
ing,  i.  205. 

irrigating,    i.    201. 

light  in,  i.  214. 

Nitze's,  i.  201. 

operating  and  photographic,  i.  202. 


Cystoscopes,  snare  attachment  to,  ii.  140. 

sterilization  of,  i.   159. 
Cystoscopic  operations,  ii.  140. 
Cystoscopy,  bladder  trabeculae  and,  i.  223. 
cystitis  and,  i.  223. 
difficulties  in,  i.  216,  229. 
direct  and  indirect,  compared,  i.  236. 
distension  hematuria  and,  i.  217. 
evolution  of,   at  author's   clinic,   i.  235. 
filling  bladder  in,  i.  212. 
history  of,  i.   198. 

in  male  and  female,  compared,  i.  237. 
introducing  instrument  in,  i.  212. 
kidney   disease  and,  i.  373. 
normal  pictures  in,  i.  220. 
patient's   position  in,   i.  212. 
questions  regarding,  i.  236. 
reaction  after,  i.   236. 
single  kidney  and,    i.    386. 
stricture  and,  i.  216. 
technique  of,  i.  210,  379. 
tuberculosis  of  kidney  and,  i.  539. 
tuberculous   infection  through,  ii.  95. 
ureteral   catheterization  and,   i.  230. 
ureteral  orifices  in,  i.  221. 
washing  bladder  in,  i.  211. 
Cystotomy,  catheter  examination  before,  ii.  5. 
perineal,  ii.   166. 

after-treatment  of,  ii.   168. 
suprapubic,  ii.   144. 

apparatus  and  instruments  for,  ii.   144. 

closing  incision  after,  ii.   160. 

formation  of  a  valve  by,  ii.   155. 

prostatic  hypertrophy  and,  ii.   154. 

technique  of,  ii.   148. 

vesical  tuberculosis  and,   ii.   154. 
Cysto-urethrotomy,  ii.  458. 
Cysts,  abdominal,  hydronephrosis  and,  i.  567. 
bladder  disturbance  due  to,   ii.    110. 
of  kidney.     See  Kidney,  Cysts  of. 

Dactylitis,  luetic,  treatment  of,  ii.  713. 
Dartos,   i.   25. 

Decapsulation  of  kidney,  i.  412.  413.  590. 
Dementia  paralytica,  lues  and,  ii.  700. 
Dermatitis,   scrotal,   ii.   563. 
Dermoid  cysts   of  spermatic   cord,   ii.    639. 
Desormeaux,  i.  3. 

Diabetes,   chronic   interstitial   nephritis    and, 
i.    426. 

general    consideration   of,    i.   364. 

uremic  coma  and,  i.   449,  450. 
Diabetes  mellitus,  complications  of,  i.  366. 

diet  in,  i.  367. 

etiology  and  pathology  of,  i.  365. 


INDEX 


675 


Diabetes  mellitus,  prognosis  in,  i.  3(JG. 

symptoms  of,  i.  3G6. 

treatment  of,  i.  3GG. 
Diabetic   baUmo-posthitis,   ii.   540, 

chronic,   treatment  of,   ii.   543. 
Diabetic  glycosuria,  i.  3(15. 
Diabetic  phimosis,   ii.   540. 
Diacetic  acid  in  urine,  i.  86, 
Diaphanoscope,  i.   199. 
Diet  in  urological  cases,  i.  323, 

nepliritis  and,  i.   435. 
Dietl's  crisis,  i.  410. 
Digital  fossa   (testes),  i.  59. 
Dilators,   covers  for,   i.   187. 

Kollmann,  i.  183,  184. 
irrigating,  i.   185. 

Oberliinder's,  i.    182, 

technique   of,   i.    185. 

urethral,   i.   182. 

urethritis   and,  ii.   394. 
Dinner  in  diet  of  urological  cases,  i.  327. 
Diplocoecus   of  gonorrhea,   i.    125. 
Discharges  from  genito-urinary  tract,  i.   117. 

in  female,  i.  130. 

table  of,  i.    128. 
Distended  bladder,  i.   47. 
DiverticuljB  in  bladder,  ii.  36. 
Donne's  test  for  pus,  i.  283. 
Doremus  urometer,  i.  8'4. 
Douche  bath,   i.   345. 
Douglas,  pouch   of,   i.   24. 
Drainage  tubes,  i.  437. 
Dressing  equipment,  office,  i.   142. 
Dropsy,  chronic  nephritis  with,  i.  422. 
Ducrey,   bacillus   of,   i.    124. 
Dumbbell  crystals,  i.   96, 
Dysuria,  i.  249,  303. 

conditions  giving  rise  to,  i.  251. 

nervous,  i.  250. 

prostatic  hypertrophy  and,  ii.  237. 

Earthy  waters,  i.  340. 
Ebers's  papyrus,  i.  1. 
Echinococcus  cyst,  ii.   115. 

prostatic,  ii.  181. 
Ectopia  of  testis,  ii.   591. 
Ectopy  of  intact  bladder,  ii.  18. 
Eczema  marginatum,  ii.  564. 
Eczema  of  penis,  ii.   523. 

scrotal,  ii.  563. 
Edema  bullosum,  ii.  38. 
Edema  bullosum  vesicir,  i.  226. 
Edema  in  nephritis,  i.  424. 

scrotal,  ii.  5G6. 

illustrative  cases  of,  ii.  566. 


Edema,  treatment  of,  i.  436. 
I'lggs  in  diet  of  urological  cases,  i.  324. 
Einhorn's  saccharometer,  i.  82. 
Ejaculatory   duct,   common,  i.    03, 

epithelia  from,  i,   103. 
Elbowed  catheters,   i.    ]()3. 
Electric  outfit   for  urological   therapeutics,   i. 

140. 
Electricity,  cystitis  and  atony  of  bladder  and, 
ii,   52, 

prostatorrhea  and,  ii.  219. 
Electrolysis,  urethral,   ii.    398. 
Electrolytic    cure    of  stricture,    ii.    468. 
Elephantiasic  orchitis,  ii.   610. 
Elephantiasis  of  penis,  ii.  528. 

of  scrotum,  ii.  568. 
operation  for,  ii.   571. 
pseudo-,    ii.    570, 
Enchondroma  of  testes,  diagnosis  of,  ii.  632. 

pathology  of,  ii.   G31. 

prognosis  in,  ii.  632, 

symptoms   of,   ii.    632. 

treatment   of,   ii.    632. 
Endocarditis,  gonococcal,  ii.  516. 
Endocervicitis,  i.   131. 

chronic,  ii.  511. 

illustrative   case   of,    ii.    117. 

metritis   and,  bladder  disturbances   due  to, 
ii.    116. 
Enema,   nutritive,   i.    329. 
Enesol,  ii.   715. 
Enteroclysis,  i.   346. 

Enteroptosis,  movable   kidney   and,   i.   405. 
Enuresis  noeturna,  sudden  micturition  in,  i, 
269. 

treatment  of,  i.  270. 
Eosinophilia,  i.   133. 
Epidectomy,  ii.   623,   635. 
Epididymis,  i.   58. 
Epididymitis,  ii.  603. 

acute,  examination  for,   ii.   606. 
prognosis  in,   ii.   607. 

catheter  life  and,  ii.  257. 

chronic  inflammatory,   ii.   617. 

etiology  of,  ii.  604. 

luetic,   ii.   694. 

treatment  of,   ii.   713, 

pathology  of,  ii,  605. 

prostatectomy  and,   ii.  303. 

symptoms  of,  ii.  605. 

treatment  of,  ii.  610. 

tuberculous.     See  Testis,  Tuberculosis  of. 
Epididj'nio-orchitis,   acute,  ii.  607. 

treatment  of,  ii.  GIO. 
Epilepsy,  uremia  and,  i.  448,  450. 


676 


INDEX 


Epispadias,  etiology  of,  ii.   321. 

operative  treatment  of,  ii.  322, 

prognosis   in,  ii.   321. 

symptoms   of,   ii.    321. 

Thiersch's  operation  for,  ii.   322. 
Epithelia   in  urine,   i.    100. 
Epithelial  casts,  i.   106. 
Epithelioma  of  penis,  ii.  529. 
.  of  prostate,  ii.  208. 
Equipment,  urological,  i.   137. 
Erb's   spinal  paralysis,   ii.   099. 
Erethism,  vesiculitis  and,  ii.  057. 
Erysipelas,  scrotal,  ii.   505. 
Erythrocytes,   1.    133. 

Esbach's   method  for  quantitative  estimation 
of  albumin,  i.  77. 

reagent,  i.   77. 
"Essential  polyuria,"  i.  271. 
Ether,  1.  350. 
Ethyl  chlorid,  i.  353. 
Eucalyptol   in  cystitis,  ii.   47. 
Evacuator  in  litholapaxy,   ii.    135. 
Examination  of  patients,  i.    308. 

external   genitals    in,   i.    312. 

prostate  and  vesicles  in,  i.  314. 
Examining  table,  i.    144. 
Exercise,   abdominal,  i.   331. 

back,  i.   331. 

chest  and  arm,  i.  332. 

outdoor,  i.  335. 

pulley  weight,  i.,331. 
Exploratory  incision,  kidney  function  and,  i. 

382. 
Exstrophy  of  bladder,  approximation  method 
for,   ii.   10. 

autoplastic  method  for,  ii.  12. 

deviation  method  for,  ii.    11. 

etiology  and    pathogenesis    of,   ii.   9. 

genital  organs  in,  ii.  9. 

hydronephrosis  and,  i.   562. 

illustrative   case  of,   ii.    12. 

Maydl's   operation  for,  ii.   11. 

pathological  anatomy  of,  ii.  8. 

pelvis  in,  ii.  9. 

symptoms   of,  ii.   10. 

treatment  of,  ii.   10. 

ureters  in,  ii.  9. 
Extirpation   of  bladder,   ii.    170. 
Extirpation  of  genital  tract,   total,   ii.   673. 
Extravasation  of  urine,  ii.  330. 

stricture   and,   ii.    416. 

Fallopian  tubes,  bladder  disturbances  due  to, 
ii.   119. 
illustrative  cases   of,   ii.    119. 


Family  history,  i.  300. 

Fat  globules  in  urinary  sediment,  i.  98. 

Fatty  casts,  i.   107. 

Fehling's  test  for  sugar,  i.  79. 

Female,  discharges  in,  i.   130. 

Female    perineum,    1.    32. 

Fermentation  test  for  sugar,  i.  81. 

Ferrein,  pyramids  of,  i.  37. 

Fibroid  tumors  of  penis,  ii.   527. 

Fibroids,    bladder    disturbances    due    to,    ii. 

108,    110. 
Fibroma  of  kidney,  1.  481. 

of  testis,  ii.  632. 
Filarial  buboes,  ii.  559. 
Filiform  bougies,   i.    319. 
Finger's   operation   of   uretero-pyeloplasty,   i. 

619. 
Fish   in  diet  of  urological  cases,   i.   325. 
Fistulas,  kidney  wounds  and,  i.  400. 

umbilico-vesical,  ii.    16. 

urethral.     See  Urethra,  Fistulas  of. 

urinary,   ii.   416. 

vesical,  ii.   43,  79. 
Floating  kidney,  i.   403. 
Fluid  diet  in  nephritis,  i.  434, 

in  urological  cases,  i.  327. 
Forceps,   i.    143. 

Foreign  bodies  in  bladder.     See  Bladder,  For- 
eign  Bodies   in. 
Formalin,   i.    153. 

Formalin   vapor,    sterilization   by,   i.    155. 
Fort,  electrolytic  method  of,  ii.  468. 
Fossa  navicularis  in  male  urethra,  i.   55. 
Fossa  ovarica,  i.  42. 

Four-tailed  bandage  in  nephrotomy,   i.   595. 
Franco,  Pierre,  i.   1. 

Freezing  methods   for   anesthesia,  i.  353, 
Frenum  of  penis,  i.  68. 
Fruits  in  diet  of   urological   cases,   i.   324. 
Fulguration  of  bladder   tumors,   ii.   75,    141. 
Fuller's  prostatectomy,  ii.   291. 
Fungus  or  hernia  testis,  ii.   033. 
Funiculitis,    ii.    639. 
Furniture  for  office,  i.   139. 

Galen,    i.   2. 

Gall-stone,  nephrolithiasis   and,  i.  513. 

Gangrene   of   bladder,   ii.    38. 

of  penis,  ii.   526. 

scrotal,  ii.  565. 
Gauze  dressings,  i.   142. 
General  symptoms  in  urological  examination, 

i.   304. 
Genital   tract,    total   extirpation   of,   ii.    673. 
Genitals,  examination  of  external,  i,  312. 


INDEX 


677 


Genito-urinary   organs,    female,    relations    of, 
i.    12. 
male,  relations  of,  i.   11. 
Genito-urinary  tract,  general  anatomy  of,  i.  9. 

location  of,   i.   15. 
Gibson's  operation  for  malignant  growths  of 

prostate,   ii.   306. 
Giemsa's  stain  for  Spirocheta  pallida,  i.   IZ'i. 
Gittler  of  Leipsic,  i.  2. 
Glands  of  Mery.      See  Cowper's  Glands. 
Glans  penis,   i.   68. 
Gleet,   ii.   413.     See  also  Urethritis,   Chronic 

Gonococcal. 
Globulin  in  urine,   i.  78. 
Globus,   major   and   minor,   of  epididymis,   i. 

58. 
Glucose   in   urine,   i.    79. 
Glycerin   in  injections,  ii.  383. 

sterilization  of,  i.   161. 
Glj'cosuria,  general  considerations  of,  i.  365. 
Gmelin's  test  for  bile  pigments,   i.   88. 
Goldhorn's    stain    for    Spirocheta    pallida,    i. 

123. 
Gonienol,   i.   161. 
in  cystitis,  ii.  51. 

in  tuberculosis   of  bladder,  ii.   104. 
Gonococcal    (or  specific)    urethritis.     See  un- 
der  Urethritis. 
Gonococcal    vulvo-vaginitis    in    children,    ii. 
513. 
complications  of,  ii.   514. 
symptoms  of,  ii.   513. 
treatment  of,  ii.   514. 
Gonococcus,  i.    125,  ii.  348. 
discovery   of,   i.    5. 
in  blood,  i.  135. 
in  urine,   i.    112. 
Gonorrhea,  bubo  and,  ii.  556. 
cystitis   and,   ii.  38. 
epididymitis   and,   ii.  604. 
in  children,  ii.  513. 

in    the    female,    abortive    treatment    of,    ii. 
509. 
acute   urethritis   from,   treatment  of,    ii. 

509. 
bartholinitis  and,  ii.   506,  513. 
bladder  in,  ii.  508. 
chronic  urethritis  from,  ii.  510. 
corporal  endometritis  and,  ii.  512. 
endocervicitis   and,  ii.   511. 
etiology  of,  ii.  501. 

examination  and   diagnosis  of,   ii.   505. 
oophoritis    (ovaritis)    from,   ii.    508. 
ophthalmia   and,  ii.   513. 
ovary   in,   ii.   504. 


Gonorrhea    in    the    female,    pathology   of,    ii. 
503. 
peritonitis   and,   ii.   508. 
I)regnancy  and,  ii.  508. 
rectal,  ii.   508. 

salpingitis   and,   ii.   508,   512. 
statistics  of,  ii.  501. 
sterility  and,  ii.  509. 
symptoms  of,  ii.  505. 
systemic  infections  and,  ii.   516. 
treatment  of,  ii.  509. 
tubes  and,  ii.  503. 
uterus   in,   ii.   503,   506,   511. 
vaccine  therapy  for,  ii.  514. 
vulva  and  vagina  in,  ii.  512. 
leucocyte  count  in,  i.  134. 
systemic   infections   from,   ii.    516. 
tuberculosis    of   bladder    and,    ii.    96. 
vaccine  therapy  for,  ii.   514. 
Gonorrheal  cystitis  and  tuberculosis  of  blad- 
der, ii.    102. 
Gonorrheal  pyelitis,  i.  463. 
Gonosan,  ii.  371. 
Gouley  tunneled  sound  and  guide,  ii.  444. 

urethrotome,  ii.   435. 
Gout,   orchitis  and,  ii.   610. 
Goutte  militaire,  ii.  357. 
Gram's  differential  stain,  i.   127. 
Granular   casts,  i.    105. 
Groin,  pain  in,  i.  302. 
Gruenf ell's  polypus  snare,  i.  191. 
"  Guide  "  in  urethrotomy,  ii.  440. 
Guinea  pig  inoculations,  i.   376. 
Guiteras  grooved  cannula,  ii.  457. 

operation  for  formation  of  new  scrotum,  ii. 

572. 
prostatectomy  operation,  ii.  288. 
prostatic  douche  tube,  ii.  212. 
recto-vesical  prostatectomy,  ii.  292. 
teaching  cystoscope,  i.  208. 
urethroscope,  i.  188. 
Gummata,  precocious,  ii.  687.     See  also  Lues. 
Gunshot  Avound  of  bladder,  ii.  20. 
Guyon's  curve  in  dilators,  i.   183. 
instillating  syringe,  i.    174. 

Haller,  aberrant  vas  of,  i.  59. 

Hands,  care  of,  i.  157. 

Harris's  index,  i.  407. 

Haste,  avoidance  of,  in  examinations,  etc.,  i. 

295. 
Heintz's  method  in  estimation  of  uric  acid,  i. 

85. 
Heller's   test  for   albumin,   i.   76. 
for  hematin,  i.  88. 


678 


INDEX 


Hematocolo,   diafrnosis  of,   ii.   5S4. 

etiolofjy  of,  ii.   583. 

pathology  of,  ii.  584. 

symptoms  of,  ii.  584. 

treatment  of,  584. 
Hematocele    of    pelvis,     bladder     disturljanee 

due  to,  ii.   119. 
Hematoidin  in  urinary  sediment,  i.   98. 
Hematuria,  i.  277. 

cystitis  and,  ii.  41. 

detection  of,  i.  278. 

distension,  cj'stoscopy  and,  i.  217. 

essential,  i.   489. 

etiology  of,  i.  277. 

hypernephroma  and,  i.  487. 

kidney  disease  and,   i.   309. 

kidney  injuries  and,  i.   392,  394. 

localization   of,   i.   279. 

nephrolitliiasis  and,   i.  507. 

salvarsan  and,  ii.  718. 

tumors  of  bladder  and,  ii.  64. 

urethritis  and,  ii.  354. 

wounds  of  bladder  and,  ii.  22. 
Hemin  crystals,  test  for,  i.  88. 
Hemoglobin,  percentage  of,  i.  132. 
Hemoglobinuria,  i.   277. 
Hemokonia,  i.   132. 

Hemorrhage,  checking  operative,  ii.  150. 
Hemorrhagic  cystitis,  i.  224,  ii.  41. 

tuberculosis  and,  ii.  99. 
Henle,  ascending  and  descending  loops  of,   i. 

37. 
Hermaphroditism,  ii.  519. 
Heredity,   in  urinary  diseases,  i.  300. 

movable  kidney  and,  i.  40G. 
Hernia,  atrophy  of  testis  from,  ii.  587. 

bladder   disturbance   due  to,   ii.   109. 

hydrocele  and  ii.  583. 

tuberculosis  of  vesicles  and,  ii.  606. 

varicocele   and,   ii.    642. 
Hernia  or  fungus  testis,  ii.  633. 
Herpes  progenitalis,  ii.  534. 
Hiccough,  prostatectomy  and,  ii.  305. 
Highmorc,  body  of,  i.  59. 
Hindoos  and  ancient  urology,  i.  1. 
Hippocrates,  i.   1. 
Hippuric  acid,  i.  86. 
History  of  case,  i.  297. 

age  of  patient,  i.  298. 

character  of  menstruation,  i.  303. 
of  urination,  i.   303. 
of  urine,  i.  303. 
civil  state,  i.  299. 
discharge,    i.    302. 
family  history,  i.  300. 


History  of  case:  occupation,  i.  298. 

|)rincipal  symptoms,  i.   301. 

race,  i.  299. 
History  of  patients,  i.  149, 
Hodgkin's  disease,  bubo  and,  ii.   558. 
Holzien's   solution,  i.  210. 
llorend  Langleberg  bandage,  ii.  612. 
Horny  growths,  penis  and,   ii.  528. 
Horseshoe  kidney,  i.  40,  384. 

diagnosis  of,  i.  385. 
Horwitz,   Orville,  extirpation  of  penis  bj',  ii. 

532, 
Hospital   and   clinic,   ecjuipment   for,  i.    150. 
Hospital  diet,  i.  327. 
Hot  Springs,  Ark.,   ii.  707. 
Hyaline  casts,  i.   105. 
Hydatid   cysts,   bladder,   enlarged,  and,   ii.   2. 

bladder  disturbances  due  to,  ii.    114. 

illustrative  cases  of,  ii.  115. 

of  kidney,  i.  496. 

prostatic,  ii.   181, 
Hydrocele,  acute,  ii.  576. 
treatment  of,   ii.  580. 

Andrews    (Wyllis)    operation  for,  ii.   582. 

bilocular,  ii.  579. 

chronic,  treatment  of,  ii.  580. 

Coley's    operation    for,   ii.   583. 

complications  of,  ii.  579. 

congenital,   ii.    578. 

diffuse,  ii.  579. 

encysted,  ii.  578,  583. 

excision  of,   ii.   581. 

hernia  and,  ii.  583. 

incision  of,  ii.  581. 

infantile,  ii.   578. 

Jaboulet's  operation  for,  ii.   581. 

Jacobson's    table   of,    ii.    574. 

medical    treatment    and    local    applications 
for,  ii.   580. 

multilocular,  ii.  579. 

pathological    anatomy  of,    ii.   576. 

periorchitis  and,   ii.    576. 

puncture    and   injection   method    of   opera- 
tion  for,  ii.   580. 

sym]itoms   of,  ii.   577. 

syphilis  and,  ii.  576. 

Iranslucency  test  for,  ii.  577. 

treatment  of,  ii.  579. 

tuberculosis   and,   ii.    578. 

varieties  of,  ii.  574. 

Volkraan's   operation   for,   ii.   581, 
Hydronephrosis,   acquired,    i.   562. 

clinical  character  of.  i.  565. 

complications  of,   i.   566. 

congenital,  i.   560. 


INDEX 


679 


Hydronephrosis,  course  of,  i.  500. 

cysts  and,  i.  507. 

diagnosis  of,  1.  5Gfl. 

etiology  of,  i.  500. 

Iieniaturia  in,  i.  505. 

kentrotomy  in,  i.  509. 

movable   kidney   and,    i.   413. 

nephrectomy  in,   i.    508. 

nei^hrotomy  in,   i.  568. 

pain  in,  1.  565. 

pathology  of,  i.  563. 

prognosis  in,   i.   567. 

Ijseudo-traumatic,  i.  392. 

puncture   contraindicated    in,    i.    568. 

pyeloplication  in,  i.  509. 

resection  of  pelvis  for,  i.  509. 

suppurative  conditions  and,  i.  500. 

symptoms  of,  i.  564,  ii.  315. 

treatment  of,  1.  567. 
surgical,   i.   508. 

ureteral  catheterization  in,  i.  508. 

uretero-pyeloneostomy  in,  i.  508. 
Hydrosalpinx,  ii.  504. 
Hydrothei-apy,  i.  344. 
Hypernephroma,   symptoms  of,   i.   487. 
Hypodermic  needles,  sterilization  of,  i.   160. 
Hypodermic  syringes,  i.   144. 

sterilization  of,  i.   160. 
Hypodermoclysis,  i.  347. 
Hypogastric  arteries,  i.  45. 
Hypospadias,  balanic,  ii.   314. 

Beck's  operation  for,  ii.  317. 

coitus  and,  ii.   315. 

diagnosis  of,  ii.  310. 

Duplay's  operation  for,  ii.  318. 

etiology  of,  ii.  314. 

operative   treatment   of,  ii.  316. 

penile,  ii.    315. 

perineal,   ii.   315. 

prognosis  in,   ii.   310. 

urethritis  and,  ii.   395. 
Hysterectomy,    ureteral   catheterizing    before, 

i.  229. 
Hysterical   anuria,   i.   275. 

Ice  bags,   i.   340. 

Icthargon,  ii.  379. 

Impotence,    douclie    for,   ii.    213. 

prostatitis   and,   ii.   208. 

tuberculosis  of  vesicles  and,   ii.   665. 
Incontinence  of  urine,  clinical  features  of    i. 
269. 

diagnosis  of,  i.   269. 

exstrophy   and,   ii.    10. 

treatment  of,  i.  270. 


Incontinonco  of  urine,  varieties  and  causes  of, 

i.  207. 
India,  frequency  of  calculus  in,  i."  499. 
Indican  in  urine,  i.  87. 
Indicanuria,  i.   301. 

etiology   of,   i.   361. 

symptoms  of,  i.  362. 

treatment  of,  i.  362. 
Jndol,  i.  361. 

absorption  of,  i.   361. 
Infections  and  leucocytosis,  i.   134. 
Infiltrates,  urethral,  ii.  410. 
Inflammatory   leucocytosis,  i.    133. 
Infusion  jars,   1.   143. 

sterilization   of,   i.    100. 
Inguinal  adenitis.     See  Bubo. 
Inguinal  glands,    ii.    554. 
Inguinal   hernia   of    bladder,    ii.    27. 

course  and   complications  of,  ii.  28. 

diagnosis   of,    ii.    28. 

illustrative  cases   of,   ii.  29. 

prognosis   in,   ii.   29. 

symptoms  of,  ii.  29. 

treatment   of,   ii.   29. 

vesical  calculus  and,  ii.  87. 
Injection    Bru,    ii.    382. 
Injections,   1.    108. 
Inosite  in  urine,  i.  83. 
Instillations,    i.    174. 

Guyon   syringe  for,   i.    174. 

into   bladder,   ii.   50. 

Ultzmann's  instrument  for,  i.   174. 
Instruments,  general   care  of,  i.    158. 

recommended,  i.   139. 

technique  of  using,  i.  103. 

used  in   operations  on   kidney,    i.   571. 
Instruments   and  apparatus,   sterilization  of, 

i.   153. 
Internal   pudic   artery,   1.   31. 
Interstitial   cystitis,  ii.   41. 
Intertrigo,   scrotal,  ii.   564. 
Intestinal  fistulas  of  umbilicus,  ii.  18. 
Intravenous  injection,  i.   348. 
lodids  in  lues,  ii.  714. 

in  nephritis,  i.  430. 
lodin  compress,   buboes  and,   ii.   559. 
lodin   test   for  bile,   i.   88. 
Irish  moss  as  a  lubricant,  i.   161. 
Irrigating  Kollmann  dilators,  i.   173. 
Irrigations,   i.    109. 

by   hydrostatic    pressure   Avithout   a   cathe- 
ter,  i.    170. 

Janet  method  for,  i.  171. 

of  urethra,  ii.  383. 

rectal,   i.   341. 


680 


INDEX 


Irrigations,  with  dilators,  i.  173. 

with   piston   syringe  and  catheter,  i.   170. 
Irrigator  jars,  sterilization  of,  i.  160. 
Irritable  testis,   ii.   G34. 
Ischio-cavcrnosus  muscles,  i.  28. 
Ischuria,  i.  249. 

Israel's  operation  for  uronephrosis,  i.   618. 
Italians,   liability  to  calculus  of,  1.  499. 
■  urinary  diseases  of,  i.  300. 

Jaboulet's  operation  for  hydrocele,  ii.  581. 
Jacobson's  classification  of  hydrocele,  ii.  574. 
Janet  irrigations,  i.    171,  ii.  49,   211,  383. 
Jewish  race,  urinary  diseases  of,  i.  300. 

K-idney,  abnormalities  of,  i.  40. 
abscess  of,  i.  473. 

etiology,  i.  474. 

examination  in,  i.  476. 

pathology  of,  i.  475. 

symptoms    of,  i.   476. 

treatment  of,  i.  476. 
anatomy  of,  i.  33. 
angles  and  triangles  of,  i.  571. 
annular,  i.  385. 
anomalies  of,  i.  383. 

in  mobility,  i.  384. 

in  number,  i.   385. 

in  position,  i.  383. 

in  shape,   i.   384. 

vascular,  i.  388. 
attachment  of,  i.  403. 
ballottement  of,  i.  371. 
blood  supply  of,  i.  39. 
chronic  suppurative  diseases  of,  i.   453. 
compensatoiy  hypertrophy  of,  i.  391. 
cysts  of,  agglomerate  form  of,  i.  494. 

hydatid  form  of,  i.  496. 

large  serous,  i.  492. 

ovarian  cysts  and,  i.  493. 
diagnosis  of,  i.  370. 
disease  of,  cystoscopy  and,  i.   373. 

nature  of,  i.  375. 

radiography  in,  i.  375. 

ureteral  catheterization  and,  i.  373. 
efficiency  tests  of,  i.  7. 
examination  of,  i.  309,  369  et  secj. 

inspection  and  palpation  in,   i.   371. 

percussion  in,   i.   372. 
fascia   of,   i.    36. 
functional  capacity  of,  i.   377. 

estimating  of,  i.   377. 

comparative  flow  of  urine  through  the 

ureteral  catheters  in,  i.  378. 
cryoscopy  test  in,  i.  379. 


Kidney,  functional  capacity  of,  estimating  of, 
exploratory  incision  in,  i.  382. 

methylene  blue  test  in,  i.  380. 

phloridzin  test  in,  i.  381. 
hematuria   and,   i.   280. 
horseshoe,  i.  384. 
injuries   of,   i.  390. 

complications   of,  i.  394. 
detachment  of  kidney   in,   i.   392. 

diagnosis  of,  i.  394. 
fistulse  following,  i.  400. 
fracture  of  ribs  and,  i.   392. 
illustrative  cases  of,  i.  396. 
incised,   punctured  and  gimshot  wounds 

as,  i.  399. 
operative  results  in,  i.  396. 
physical  signs  of,  i.   393. 
prognosis  in,  i.  395. 
pseudo-traumatic  hydronephrosis  after,  f. 

392. 
regeneration   after,  i.   390. 
shock  after,  i.  393. 
subparietal,  i.   391. 
symptoms  of,  i.  391. 

local,   i.    393. 

urinary,  i.  392. 
treatment  of,  i.  396. 
instruments  used  in  operating  on,  i.  571. 
lobulation  of,  i.  384. 
location  of,   i.   19. 
movable,  i,  403. 

abdominal  supports  in,  i.  415. 
body  index  and,   i.  406. 
complications  of,  i.  414. 
decapsulation  for,  i.   412. 
diagnosis   of,   i.   413. 
Dietl's  crisis  in,  i.   410. 
enteroptosis  and,  i.  405. 
etiology   of,   i.   404. 
exercise  for,  i.  417. 
Harris's  index  in,  i.  407. 
heredity  in,  i.  406. 
nephrectomy  in,  i.  417. 
nephrolithiasis  and,  i.  512. 
physical  examination  for,  i.  412. 
prognosis  in,  i.   415. 
symptoms   of,   i.  410. 

gastro-intestinal,   i.  411.  •* 

nervous,  i.  411. 

pain  in,  i.  410. 
traumatism  and,  i.  406. 
treatment  of,  i.  415. 
tuberculosis  of  kidney  and,  i.  543. 
timior  and,  i.  414. 
urination  in,  i.  411. 


INDEX 


681 


Kidney,    movable,    Weir-Mitchell    cure    in,    i. 
415. 
operative  surgery  of,  i.  570. 
body  holder  for,  i.  576. 
explorations  in,  i.  582. 
incisions  in,  i.  572. 
operations  in,  i.  584. 

delivery  of  kidney,  i.  570. 
nephrectomy,  i.   601. 

anterior  or  transperitoneal,  i.  614. 
by  morcellement,  i.  010. 
by  transverse  incision,  i.  61.3. 
partial,  i.  610. 
secondary,  i.  601. 
subcapsular,  i.  601. 
nephropexy,  i.  584. 
nephrostomy,  i.   598. 
renal  decapsulation,  i.  590. 
position  of  patient  in,  i.  575. 
technique  of,  i.  577. 
pelvis  of,  i.  36. 
regeneration  of,  i.  390. 
relations  of,  i.  34. 
scar  formation  in,   i.  390. 
single  and  nonfunctionating,  i.  374. 
stone  in,  i,   499.     See   also  Xephrolithiasis. 
structure  of,  i.  37. 
suppurative  diseases  of,  tuberculosis  and,  i. 

529. 
tuberculosis  of,  aspiration  in,  i.  548. 
calculus  and,  i.  541. 
capsule  in,  treatment  of,  i.  549. 
caseating  form  of,  i.  528. 
climate  and,  i.  555. 

complications  after  operation  for,  i.  551. 
conclusions  on,  i.  558. 
cutaneous    and   ophthalmo-reaction   tests 

in,  i.  593. 
cystic  kidney  and,  i.  544. 
cystoscopy  and,  i.  539. 
diagnosis  of,  i.  536. 
differential  diagnosis  of,  i.  541. 
drugs  in,  i.  553. 
etiology  of,  i.  526. 
fever  in,  i.  536. 

guinea-pig  inoculations  in,  i.  538. 
hematuria  in,  i.  530. 
"  historical  data  on,  i.  525. 
illustrative  cases  of,  i.  555. 
lesions  associated  with,  i.  533. 
method  of  life  in,  i.   553. 
miliary  form  of,  i.  527. 
nephritis,  hemorrhagic,  and,  i.  543. 
nonfunctionating  or  derelict  kidneys  and, 
i.  552. 


Kidney,  tuberculosis  of,  pathology  of,  i.  527. 
perinephritic  abscess  and,  i.  550. 
polyuria  in,  i.  530. 
primary  form  of,  i.  527. 
pyuria  in,  i.  536. 
reno-renal  reflex  in,  i.  535. 
secondary  suppurative  processes  in,  i.  527. 
smegma  bacillus  and,  i.  538. 
symptoms  of,  i.  533. 
general,  i.  536. 
objective,  i.  536. 
pain  in,  i.  535. 
subjective,  i.  534. 
tenderness  in,  i.  537. 
tenesmus  in,  i.  535. 
treatment  of,  i.  544. 
history  of,  i.  545. 
medical,  i.  552. 
operative,  i.  546. 

nephrectomy  statistics  in,  i.  559. 
peritonitis  following,  i.  551. 
results  of,  i.  551. 
tubercle  bacillus  in,  i.  538. 
tuberculin  test  in,  i.  539. 
tumor  in,  i.  536. 
tumor  of  kidney  and,  i.  542. 
ureter  in,  removal  of,  i.  548. 
ureteral  catheterization  in,  i.  540. 
ureteral  occlusion  following,  i.  530. 
urination  in,  frequency  of,  i.  535. 
urine  in,  i.  537. 
tubes  and  blood  vessels  of,  i.  38. 
tumors  of,  i.  480. 
abscess  and,  i.  488. 
benign,  i.  480. 
adenoma,  i.  481. 
angioma,  i.  481. 
fibroma,  1.  481. 
lipoma,  i.  481. 
myxoma,  i.  481. 
bladder-tumor  and,  i.  488. 
calculus  and,  i.  488. 
hematuria  and,  i.  280. 
hydronephrosis  and,  i.  488. 
liver-tumor  and,  i.  488. 
malignant,  i.  481. 
diagnosis  of,  i.  487. 
etiology  of,  i.  481. 
pathology  of,  i.  482. 
adenoma,  i.  482. 
carcinoma,  i.  482. 
hypernephroma,  i.  484. 
rhabdomyoma,  i.  484. 
sarcoma,  i.  483. 
.  prognosis  of,  i.  489. 


682 


INDEX 


Kidney,  tumors  of,  malignant,  symptoms  of, 
i.  4SIJ. 
treatment  of,  i.  489. 
metastases  from,  i.  490. 
nephrolitliiasis  and,  i.  512. 
pyonephrosis  and,  i.  4SS. 
splenic  tumors  and,   i.   4S9. 
tuberculosis  of  kidney  and,  i.  4SS,  542. 
tumors  of  pelvis  of,  i.  491. 
Kidney  pad,  i.  432. 
Kollmann's  dilators,  i.  183,  184,  ii.  420. 

Laboratory,  1.  148. 

Labyrinth    (in  kidney),  i.  37. 

Lactate  of  strontium,  nephritis  and,  i.  429. 

Lactose  in  urine,  1.  83. 

Lafayette  mixture,  ii.  372. 

Largin,  ii.  379. 

Larynx,  lues  and,  ii.  695. 

Lau*nt  penumbra  polarizing  saccharometer, 

i.  80. 
Laxatives,  i.  330. 
Leiter,  i.  3. 

Lepra  bacillus,  i.   113. 

Leucin  and  tyrosin  in  urinary  sediment,  i.  97. 
Leucin  in  urine,  i.  89. 
Leucocytes,  varieties  of,  i.  133. 
Leucocytosis,  i.  133. 

and  infections,  i.   134. 
Leucorrhea,  i.   131. 

gonorrhea  in  female  and,  ii.  505. 
Levator  ani  muscle,  i.  20. 
Levulose  in  urine,  i.  83. 
Lieben's  test  for  acetone,  i.  87. 
Ligaments  of  pelvic  floor,  i.  19. 
'   of  bladder,  i.  48. 
Lipoma  of  kidney,  i.  481. 

of  spermatic  cord,  ii.  G38. 
Lipuria,  i.  98. 

Lister's  "  antiseptic  method,"  i.  G. 
Lithia  waters  for  urological  cases,  i.  340. 
Litholapaxy,   ii.   135. 
Lithotomy,  perineal,  ii.  1G7. 

suprapubic,  ii.   150. 

vesical  calculus  and,  ii.  93. 
Lithotrite,  Thompson's,  ii.  134. 
Lithotrity   and  litholapaxy  without  the   cys- 

toscope,  ii.   133. 
Littlejohn  serum  for  lues,  ii.  710. 
Littre,  glands  of,  i.  5G,   19G,  ii.  35G. 

periurethritis  and,  ii.  477. 
Lobulated  kidney,  i.  40,  384. 
Local  anesthesia,  i.  352. 
Locomotor  ataxia,  ii.  699. 
Lohnstein's  saccharometer,  i.  82. 


Loin,  pain  in,  i.  301. 
Lubricants,  ii.  302. 

author's  formula  for,  i.  162. 

for  catheters,  i.  203. 

sterilization  of,  i.  161. 
Lubrichondrin,  i.  185. 
Bues,  ii.  675.     See  also  Sj-philis. 

aeneiform  lesions  in,  ii.  (583. 

Aix  la  Chapelle  and,  ii.  707. 

alopecia  in,  ii.  688. 

annular  syphilids  in,  ii.  681. 

ataxic  paraplegia  of,  ii.  699. 

Bacelli's  solution  for,  ii.  710. 

baths  in,  ii.  707. 

bubo  and,  ii.  679. 

cerebral  gumma  of,  ii.  696. 

condj'lomata  in,  ii.  680. 

contagion  in,  ii.  720,  721. 

corona  veneris  in,  ii.  682,  710. 

cure  of,  ii.  720. 

cutaneous  tertiary  lesions  of,  ii.  690. 

definition  of,  ii.  675. 

dementia  paralytica  and,  ii.  700. 

description  of,  ii.   076. 

ecthymatous  eruption  in,  ii.  685. 

Eichler's  method  for,  ii.   708. 

epididymis  and,  ii.  094. 

epilepsy  of,  ii.  697. 

Erb's  spinal  paralysis  and,  ii.  699. 

exposure,  incubation  and  first  stage  of,  ii. 
676. 

eye  in,  ii.  688. 

fumigations  in,  ii.  710. 

genito-urinary  system  in,  ii.  G93. 

grand  and  petit  mal  of,  ii.  697. 

gummata  in,  ii.  692. 
of  cord,  ii.  699. 
of  testes,  ii.   694. 
precocious,  ii.  687. 

headaches  due  to,  ii.  695. 

hemiplegias  of,  ii.   696. 

hereditary,  ii.  714. 

histbry  of,  ii.  675. 

Hot  Springs,  Arkansas,  regime  for,  ii.  707. 

hygiene  and,  ii.  721. 

impetiginous  lesions  of,  ii.  685. 

injections  for,  ii.  708. 

insontium,  ii.  677. 

inunctions  in,  ii.  706,  708. 

keloids  in,  ii.  692. 

Keyes's  treatment  of,  ii.  704. 

larynx  and,  ii.  695. 

lenticular  lesions  of,   ii.   682. 

Littlejohn  serum  for,  ii.  710. 

locomotor  ataxia  and,  ii.  G99. 


INDEX 


683 


lilies,  lungs  and,  ii.  605. 

macular  sypliilids  in,  ii.  GSO. 

mercurial   injections  into  the  veins  for,   ii. 

710. 
mercury  in,  ii.  704,  720. 
mixed  treatment  for,   ii.  700. 
mouth  and  teeth  in,  ii.  722. 
mouth  and  throat  in,  ii.  G87. 
mucous  patches  in,  ii.  088, 

on  fjenitals,  ii.  G89. 
nail  affections  in,  ii.  088. 
nervous  system  and,  ii.  695. 
neuralgia  and,  ii.  700. 
neuritis  and,  ii.  700. 
Noguchi's  skin  test  for,  ii.  723. 
of  spermatic  cord,  ii.  041. 
onj'chia  in,  ii.   688. 
osteoperiostitis  in,  ii.  693. 
palate  and,  ii.  694. 
palmar  syphilids  in,  ii.   710. 
papular  lesions  of,  ii.  681. 
papulo-squamous  lesions  of,  ii.  682. 
paralysis   (Erb's  spinal)   in,  ii.  699. 
paraplegia   due  to   meningo-myelitis   of,   ii. 

698. 
paresis  and,  ii.  700. 
paresthesia  in,  ii.  698. 
periostitis  in,  ii.  693. 
pigmentary  lesions  of,  ii.  687. 
posterior  spinal  sclerosis  and,  ii.  699. 
prevention  of,  ii.  722,  723. 
prognosis  in,  ii.  689. 
psoriasis  vulgaris  and,  ii.  682. 
psoriatic  lesions  of,  ii.  682. 
pustular  syphilids  in,  ii.  683. 
respiratory  tract  and  tertiary,  ii.  694. 
rupia  in,  ii.  686,  691. 
saddle-nose  from,  ii.  694. 
salivation  in,  ii.  705. 
sarcocele  in,  ii.  694. 
secondary,   ii.   679. 
serpiginous  syphilids  in,  ii.  692, 
sexual  intercourse   and,  ii.   721. 
skin  discolorations  in,   ii.   692. 
special  manifestations   of,  ii.  687. 
tabes  and,  ii.  699. 
tertiary,  ii.  689. 
testes  in,  ii.  693. 
thermal  springs  and,  ii.  707. 
third  period  of  quiescence  in,  ii.   689. 
treatment  of,  ii.  701. 

alopecia  in,  ii.  711. 

angina  in,  ii.  711. 

arsenical  preparations  in,  ii.  715. 

atoxyl  in,  ii.  715. 


Lues,  treatment  of,  constitutional,   ii.  703. 
diet  list  in,  ii.  722. 
information   for  patients   in,  ii.   720. 
initial    li'sioii    in,   ii.   701. 
niiiilc  ot"  life  in,  ii.   722. 
nl()i^1    jjapulcs  in,   ii.   711. 
nnicous  patches  in  iiioutli    in,   ii.  711. 
salivation  in,  ii.  712. 
salvarsan      ("600")      in.      See     Salvar- 

san. 
serum,  ii.  710. 
treatment  of  secondary,  ii.  704. 
treatment   of   special    secondary   manifesta- 
tions, ii.  710. 
treatment  of  tertiary,  ii.  712. 
l)one  syphilis  and,  ii.  713. 
dactylitis  and,   ii.   713. 
enesol  in,  ii.  715. 
epididymitis  and,  ii.   713. 
iodids  in,  ii.  714. 
iodism  in,  ii.  714. 
nervous  lesions  in,  ii.  713. 
orchitis  and,  ii.  713. 
pharj'ngitis  and,  ii.  713. 
rhinitis  and.  ii.  713. 
tubercular  syphilids  and,  ii.  690'. 
Turkish  baths   and,  ii.  721. 
unfavorable  cases  of,  ii.  720. 
variolaform  eruption  in,  ii.  685. 
"  Luetic  phthisis,"  ii.  695. 

Lukomsky's  case  of  hermaphroditism,  ii.  519. 
Lupus  of  penis,  ii.  524. 
Limch  in  diet  of  urological  cases,  i.  327. 
Lymph  scrotum,  ii.  568. 
Lymphadenoma  of  testis,  ii.  632. 
Lymphangitis,  penis  and,  ii.  525. 
Lymjshatic     and     suppurative     affections     of 

penis,  ii.  525. 
Lymphocytes,  i.  133. 
Lymphocytosis,  i.  133. 

Macular   syphilids,  ii.   6S0. 

^IcGill's  suprapubic  prostatectomy,  ii.  291. 

^lagiiesium  fluid,  i.  91. 

Maisonneuve,  i.   3. 

urethrotome  of,  ii.  437. 
Malaria,  nephrolithiasis  and,  i.  512. 

orchitis  and,  ii.  610. 

pyelo-nephritis  and,  i.  459. 
^lalecot's  catheter,  i,  167. 
]\[alpighi,  pyramids  of,  i.  37. 
^lalpighian  corpuscle,  i.  38. 
jMandrins,  i.  166,  ii.  4. 
^Marriage,  gonorrhea  and,  ii.  401. 
Martin's  operation  for  sterility,  ii.  615. 


684 


INDEX 


Massage,  of  seminal  vesicles,- ii.  603. 
Massage  vibrator,  i.  14G. 
Mauriac,  diffused  chancre  of,  ii.  545. 
Maydl's  operation  for  exstrophy,  ii.  11. 

operation    for    transplantation    of    iiretei-s 
"with  intestine,  ii.  133. 
Measles,  prostatic  abscess  and.   'i.  202. 
Meat  in  diet  of  urological  cases,  i.  325. 
Meatotomy,  ii.  433. 

urethritis  and,  ii.  393. 
Meatus,  1.  68. 

anomalies  of,  ii.  309. 
chancre  of,  ii.  702. 
congenital  stricture  of,  ii.  310. 
Mediaeval  urology,  i.  2. 
Melancholia,  retained  testicle  and,  ii.  590. 
Melanin  in  urine,  i.  89. 
Meningitis,  uremia  and,  i.   448,  450. 
Menstruation,  gonococcal  infection  during,  ii. 

363. 
Mercuric  oxj'cyanid,  i.  153. 
Mercurol,  ii.  380. 
Mercury,  preparations  of,  ii.  704. 
Mesure  of  Venice,  i.  2. 
Metabolism,  diseases  of,  i.  358. 
Meteorism,  kidney  injuries  and,  i.  394. 
j\Iethylene  blue  test  in  examination  of  kidney 

function,  i.  380. 
Metritis    and   endometritis,    bladder    disturb- 
ances due  to,  ii.  IIG. 
Micrococcus  urese,  i.  115. 

discoveiy  of,  i.  5. 
Micturition,  calculus  and,  i.  241. 
catheterization  and,  ii.  G. 
causes  affecting,  table  of,  i.  245. 
character  of,  i.  303. 
diet  and,  i.  246. 

dilatation  of  sigmoid  and,  i.  245. 
disease  outside  urinary  tract  and,  i.  244. 
disturbances  of,  i.  239. 

changes  in  urinaiy  stream,  i.  253. 
dysuria,  i.  249. 
frequency  of  urination,  i.  239. 
etiology  of,  i.  240. 
treatment  of,  i.  248. 
incontinence  of  urine,  i.  267. 
painful  micturition,  i.  252. 
retention  of  urine,  i.  255. 
frequent,  tuberculosis  of  kidney  and,  i.  535. 
impediments  to,  i.  241. 
inducing,  at  examination,  i.  313. 
paretic  cystitis  and,   ii.   40. 
periurethral  abscess  and,  i.  242. 
posture  and,  ii.  39. 
precipitate,  in  cystitis,  ii.  39. 


Micturition,    prostatic    hypertrophy    and,    i. 
243. 

prostatitis  and,  i.  242. 

salpingitis  and,  i.  245. 

seminal  vesiculitis  and,  i.  244. 

stone  and,  ii.  40. 

strictures  and,  i.  243. 

tuberculous  cystitis  and,  ii.  40. 

tumoi's  of  Ijladdcr  and,  ii.  66. 
pelvis  and,  i.  245. 

urethritis  and,  i.  242. 

uterine  displacements  and,  i.  244. 

vesical  tuberculosis  and,  i.  241. 

vesical  tumor  and,  i.  241. 
Mignon  or  cold  lamj),  i.  3,  189,  204. 
Migraine,  uremia  and,  i.  444. 
Milk  diet  in  nephritis,  i.  433. 
Milk  leg,  ii.  407.' 
Mineral  waters  in  cystitis,  ii.  48. 

in  urological  cases,  i.  338. 
Mixed  leucocytosis,  i.  133. 
Modern  urology,  i.  3. 
Molds,  i.  115. 

Morgagni,   crypts   of,   ii.   356. 
Movable  kidney,  i.  403.     See  also  Kidney. 

operation  for,  i.  584. 
Mucin,  in  urine,  i.  79. 

test  for,  i.  282. 
]\Iucous  cystic  tumors  of  penis,  ii.  527. 
Mucous  patches,  ii.  688. 

preputial,  ii.  537. 
Mucus  in  urine,  i.  79,  282. 
Mumps  and  orchitis,  ii.  609. 
Myocarditis,  gonococcal,  ii.  516. 
Myoma  of  testis  and  epididymis,  ii.  633. 
Myxoma  of  kidney,  i.  481. 

of  testis  and  epididjTnis,  ii.  633. 

Xeedles,  i.  143. 

Xeedling    the    kidney,    in    nephrolithiasis,    i. 

516. 
Xeisser's  gonococcus,  ii.  348. 

discovery  of,  i.  5. 
Nephralgia,  nephrolithiasis  and,  i.  512. 
Xephrectomy,  i.  601. 

accidents  in,  i.  605. 

after-treatment  of,  i.  550. 

Albarran's  method  in,  i.  609. 

anterior  or  transperitoneal,  i.  614. 

anuria  after,  i.  606. 

closing  the  wound  in,   i.   612. 

complications  after,  i.  606. 

danger  of,  i.  604. 

first,  by  Paeslee,  i.  4. 

hemorrhage  after,  i.  604. 


i:e^dex 


685 


Nephrectomy,  hemorrhage  from  an  accessory 
artery  in,  i.  605. 

from  vena  cava  in,  i.  606. 
in  hydronephrosis,  i.  508. 
in  movable  kidney,  i.  417. 
in  nephrolithiasis,  i.  517. 
in  tuberculosis  of  kidney,  i.  .'540,  547. 
indications  for,  i.  377. 
infection  of  wound  after,  i.  G07. 
morcellement,  i.  010. 
peritoneum  in,  wounding  of,  i.  005. 
pleura  in,  opening  of,  i.  005. 
secondarj^,  i.  608. 
shock  after,  i.  607. 

statistics  of,  in  renal  tuberculosis,  i.  559. 
subcapsular,  i.  608. 
suppurating  sinuses  after,  i.  607. 
transperitoneal  or  anterior,  i.  614. 
transverse  incision  in,  i.  613. 
ureter  in,  treatment  of,  i.  605. 
Nephritis,  acute,  i.  419. 

acute-transient  form  of,  i.  420. 

cold  and,  i.  419,  420. 

diagnosis  of,  i.  422. 

etiology  of,  i.  419. 

hyperacute  form  of,  i.  420. 

pathology  of,  i.  419. 

scarlatinous  form  of,  i.  421. 

subacute  form  of,  1.  420. 

suppurative,  form  of,  i.  478. 

symptoms  of,  i.  420. 

treatment  of,  i.  428. 
d  frigore,  i.  420. 
alcohol  in,  i.  434. 
aspiration  for  dropsy  of,  i.  437. 
decapsulation  for,  i.  412. 
benzoate  of  soda  in,  i.  429. 
chlorid-free  diet  in,  i.  433. 
chronic,  i.  422. 

treatment  of,  i.  429. 
chronic  interstitial,  cardiac  stage  of,  i.  427. 

compensation  stage  of,  i.  427. 

diabetes  and,  i.  426. 

diagnosis  of,  i.  427. 

etiology  of,  i.  425. 

pathology,  i.  426. 

prognosis  in,  i.  428. 

symptoms  of,  i.  427. 

uremic  stage  of,  i.  427. 
chronic  parenchymatous,  course  of,   i.  424. 

diagnosis  of,  i.  425. 

etiology  and   pathogenesis  of,   i.  422. 

pathology  of,  i.  423. 

symptoms  of,  i.  424. 
cysts  due  to  interstitial,  i.  492. 


Xcphritis,  decapsulation  of  kidney  for,  i.  430. 

(lillusn,  i.  425. 

od<'nia  in,  i.  430. 

fluid  diet  in,  i.  434. 

hematuria  and,  i.  280. 

hemorrhagic,  tuberculosis  of  kidney  and,  i. 
543. 

hygiene  in,  i.  435. 

iodids  and,  i.  430. 

kidney  pad  for,  i.  432. 

lactate  of  strontium  for,  i.  429. 

milk  diet  in,  i.  433. 

nonsuppurative,  i.  418. 

organotherapy  in,  i.  430. 

traumatic,  i.   394. 

treatment  of,  i.  428. 
general,  i.  431. 
symptomatic,  i.  436. 
Nephrolithiasis,  anuria  and,  i.  522. 

appendicitis  and,  i.  513. 

diagnosis  of,  i.  504. 

diet  in,  i.  513. 

differential  diagnosis  of,  i.  511. 

etiology  of,  i.  499. 

examination  in,  i.  507. 

exploratory  nephrotomy  in,  i.  511. 

gall-stone  and,  i.  513. 

hematuria  in,   i.   507. 

malaria  and,  i.  512. 

mortality  after  operation  in,  i.  521. 

nephralgia  and,  i.  512. 

nephrectomy  for,   1.   517. 

nephrostomy  and,  i.  517. 

occurrence  of,  i.  501. 

operative  treatment  of,  i.  514. 

pain  in,  i.  504. 

pathology  of,  i,  502. 

pyelotomy  for,  i.  515. 

pyuria  in,  i.  507. 

radiography  and,  i.  509. 

reflex  pains  of,  i.  506. 

reno-renal  reflex  in,  i.  500. 

septic  and  aseptic,  i.  509. 

symptoms  of,  i.  fK)4. 

temperature  and  pulse  after  operation  for. 
i.  519. 

treatment  of,  i.  513. 

tuberculous  kidney  and,  i.  511. 

urine  after  operation  for,  i.  520. 

urine  in,  i.  508. 

varieties  of,  i.  500, 
Nephropexy,  i.  584. 

after-treatment  of,  i.  589. 

in  hydronephrosis,  i.  509,  017. 
Nephrostomy,  i.  598. 


686 


INDEX 


Xephrostomy,  drainage  after,  i.  GOO. 

in  nephrolithiasis,  i.  517. 

in  tuberculosis  of  kidney,  i.  546. 

in  tumors  of  bladder,  ii.  76. 
Nephrotomy,  i.  590. 

complications  of,  i.  595. 

drainage  after,  i.  597. 

hemorrhage  in,  i.  595. 

in  hydronephrosis,  i.  568. 

in  nephrolithiasis,  i.  516. 

in  tuberculosis   of  kidney,   i.   546. 

sinuses  after,  i.  597. 
Kephro-ureterectomy,  i.  665. 
Nervous  lesions  of  lues,  treatment  of,  ii.  713. 
"  Nervous  polyuria,"  i.  272. 
Neuralgia  of  testicle,  ii.  634. 
Neuralgic  herpes,  preputial,  ii.  535. 
Neurasthenia,  prostatitis  and,  ii.  203,  208. 

retained  testis  and,  ii.  589. 
Nitric  acid  test  for  albimiin,  i.  76. 
Nitrous  oxid,  in  anesthesia  in  urological  cases, 

i.  351. 
Nitze,  i.  3,  5. 

cystoscope  of,  i.  201. 

operating  cystoscope  of,  ii.   143. 
Nitze-Albarran  cystoscope,  i.  203. 
Noguchi's  skin  test  for  lues,  ii.  723. 
Nocturnal  pollutions,  prostatitis  and,  ii.  208. 
Nonspecific  urethritis,  i.    121. 
Nubecula,  i.  73. 
Nucleo-albumin  in  urine,  i.  76. 
Nutrition,  i.  304. 
Nylander's  test  for  sugar,  i.  80. 

Oberlander,  dilators  of,  i.  182,  ii.  426. 

on  urethritis,  ii.  356. 
Occupation  of  patients  in  diagnosis  of  cases, 

i.  298. 
Odor  in  diagnosis  of  cases,  i.  305. 
Office,  arrangement  of,  i.  137. 

arrangement  of  author's,  i.  144. 

management  of,  i.   148. 
Oliguria,  i.  276. 

kidney  injury  and,  i.  393. 
Omentum,  bladder  disturbances  and,  ii.   125. 

illustrative  cases  of,  ii.   126. 
Onychia,  luetic,  ii.   688. 
Oophoritis,  gonorrhea  and,  ii.  508. 
Operating  table,  i.  575. 
Ophthalmia,  gonorrhea  and,  ii.  513. 
Opium   poisoning,   uremic  coma   and,   i.    448, 

450. 
Orchidectomy,  ii.  636, 
Orchitis,  acute,  complications  of,  ii.  609. 
scarlet  fever  and,  ii.  610. 


Orchitis,  acute,  etiology  of,  ii.  604. 

luetic    (syphilitic),  diagnosis  of,  ii.  626. 
etiology  and  frequency  of,  ii.  025. 
pathology  of,  ii.  625. 
symptoms  and  course  of,  ii.  626. 
treatment  of,  ii.  627,  713. 

malaria  and,  ii.  610. 

Paquelin  cautery  in,  ii.  013. 

pathology  of,  ii.  005. 

rheumatism  and,  ii.   010. 

smallpox  and,  ii.  009. 

sj-mptoms  of,  ii.  005. 

typhoid  and,  ii.  609. 
Organotherapy  in  nephritis,  i.  430. 
Osteoma  of  testis  and  epididymis,  ii.  633. 
Otis,  i.  3. 

urethrometer  of,  ii.  419. 

urethrotome  of,  ii.  435. 
Outside  visits,  equipment  for,  i.  140. 
Ovarian  cysts,  kidnej-  cysts  and,  i.  493. 
Ovarian  tumors,  bladder  disturbances  and,  ii. 

113. 
Ovaritis,  gonorrhea  and,  ii.  508. 
Oxalate,  calcium  crystals,  i.  96. 
Oxaluria,  diet  in,  i.  364. 

etiology  of,  i.  303. 

treatment  of,  i.  363. 
Paeslee,  first  nephrectomy  by,  i.  4. 
Pain,  diagnosis  from,  i.  301. 

kidney  trouble  and,  i.  369. 
Painful  micturition,  i.  252. 
Pampinifoi-m  plexus,  i.  60,  ii.   641. 
Paquelin   cautery,  orchitis   and  the,   ii.    613. 
Paracelsus,  i.  2. 
Paracentesis,  i.  203. 
Parafrenitis,  ii.  478. 
Paraphimosis,  ii.  543. 

treatment  of,  ii.  551. 
Paravesical  fossa,  i.  48. 
Pare,  Ambrose,  i.  2. 
Paresis,  general,  ii.  700. 
Parotitis  and  orchitis,  ii.  009. 
Pasteur  and  Micrococcus  ureae,  i.  5. 
Patients,  examination  of,  i.  30S. 
Pawlik,   ureteral   catheterization  by,   i.  4. 
Pearl  bodies  in  prostate,  ii.  186. 
Pectiniform  septum  in  penis,  i.  68. 
Pediculosis,  ii.  565. 
Pelvic  cellulitis  in  male,  ii.  198. 
Pelvic  fascia,  i.  22. 

Pelvic  inflammations  and  adhesions,  ii.  116. 
Pelvis,  i.  19. 

blood  vessels  of,  i.  25. 

fracture  of,  bladder  rupture  and,  ii.  24. 
Pelvis  of  kidney,  i.  36. 


INDEX 


687 


Pelvis  of  kidney,  tumors  of,  1.  491. 
Penis,  i.  G7. 

abnormalities  of,  ii.  518. 

abscess  of,  ii.  52G. 

adenoma  of,  ii.  528. 

amputation  of,  ii.  531. 

blood  vessels  of,  i.  69. 

cellular  inflammation  of,  ii.  526. 

congenital  blind  pouches  of,  ii.  520. 

corona  of,  1.  68. 

cutaneous  affections  of,  ii.  523. 

deformed,  ii.  518. 

hermaphroditism  and,  ii.  519. 
Boudareff's  case,  ii.  519. 
Lukomsky's  case,  ii.  519. 

dislocation  of,  ii.  523. 

eczema  of,  ii.   523. 

elephantiasis  of,   ii.   528, 

epithelioma  of,  ii.  529. 

extirpation  of,  ii.  532. 

fracture  of,  ii.  522. 

gangrene  of,  ii.  526. 

horny  growths  of,  ii.  528. 

lupus  of,  ii.  524. 

lymphangitis  of,  ii.  525. 

lymphatic  and  suppurative  affections  of,  ii. 
525. 

lymphatics  of,  i.   69. 

nerves  of,  i.  69. 

roots  of,  i.  67. 

sarcoma  of,  ii.  534. 

scabies  of,  ii.  524. 

scirrhous  cancers  of,  ii.  529. 

strangulation  of,  ii.  521. 

structure  of,  i.   69. 

tuberculosis  of,  ii.  525. 

tumors  of,  ii.  527,  529. 

wounds  of,  ii.  521. 
Penitis,  ii.  352,  526. 
Peptonized   milk,  1.   329. 
Pericystitis,  ii.  38,  42. 
Perineal  and  vaginal  hernias  of  the  bladder, 

ii.  31. 
Perineal  body,  i.  26. 
Perineal  cystotomy,  ii.   166. 

after-treatment  of,  ii.  168. 
Perineal  lithotomy,  ii.  167. 
Perineorrhaphy  in  male,  ii.  488. 
Perinephritic  abscess,  calculus  and,  i.  472. 

course  of,  i.  471. 

diagnosis  for  source  of,  i.  469. 

diagnosis  of,  i.  468. 

etiology  of,  i.  466. 

examination  in,  i.  468. 

nephrolithiasis  and,  i.  522. 


Perinephritic  abscess,  psoas  abscess  and,  i.  472. 

symptoms  of,  i.  468. 

treatment  of,  1.  472. 

tuberculosis  of  kidney  and,  i.  550. 
Perineum,  anatomy  of,  i.  25. 

female,  i.  32. 

pain  in,  i.  302. 
Periorchitis,  ii.  576. 
Perirenal  tissue,  i.  36. 
Perirenal  tumors,  i.  491. 
Peritoneum,  1.  23. 
Peritonitis,  gonorrhea  in  female  and,  ii.  508. 

kidney  injuries  and,  i.  394. 

leucocyte  count  in,  i.   134. 
Periurethral  abscess,  in  female,  ii.  503. 

micturition  and,  i.  242. 

stricture  and,  ii.  416. 

urethrectomy  for,  ii.  468. 
Periurethritis,  chronic,  ii.  476,  479. 

etiology  of,  ii.  474. 

extension  of,  ii.  475. 

extravasation  of  urine  in,  ii.  477. 

illustrative  case  of,  ii.  478. 

Littre's  glands  and,  ii.  477. 

membranous,  ii.  480. 

multiple  abscesses  in,  ii.  478, 

obstruction  and,  ii.  475. 

parafrenitis  and,  ii.  478. 

pathology  of,  ii.  476. 

slow  leakage  of  urine  and,  ii.  479. 

symptoms  of,  ii.  477. 

treatment  of,  ii.  479. 
Perivesiculitis,  ii.  654. 
Permanganate  irrigation,  ii.  386. 
Perspiration,  urine  compared  with,  i.  437. 
Petit's  triangle,   i.   577. 
Pezzer's  catheter,  i.   167. 
Phagedenic  chancre,  ii.  536. 
Phagedenic  ulceration  in  lues,  ii.  702. 
Phagocytosis,  i.  134. 
Phantom  bladder,  i.  227. 
Pharyngitis,  luetic,  treatment  of,  ii.  713. 
Phenol,  i.  87. 

Phenyl -hydrazin  test  for  sugar,  i.  81. 
Phimosis,  ii.  543, 

diabetic,  ii.  540. 
Phloridzin  test  for  functional  capacity  of  kid- 
ney, i.  7,  381. 
Phosphates  in  urinary  sediment,  i.  97. 

in  urine,  i.   282. 
Phosphatic  diathesis,  vesical  calculus  and,  ii. 

83. 
Phosphaturia,  i.  367. 

calculi  and,  i.  367. 

diet  in,  i,  368. 


688 


INDEX 


Phosphaturia,  treatment  and,  i.  3G8. 
Phtliisis,  luetic,  ii.  095. 
Physiological  leucocytosis,  i.   133. 
•Piston  syringes,  sterilization  of,  i.   159. 
Pitard,  Jean,  i.  2. 
Plaster,  surgical,  i.  143. 
Pneumaturia,  i.  280. 
Poggl    operation    in    iiretero-uretorostomy,    i. 

658. 
Pollakiuria,   i.  239. 
Polyorchism,  ii.  580. 
I'olyjDus  snare,  i.  191. 
Polyuria,  i.  271. 

etiology  of,  i.  240,  271. 
kidney  injuiy  and,  i.  393. 
Posthemorrhagic  leucocytosis,  i.    135. 
Posthitis,  ii.  538. 
Posture,   in   diagnosis    of   iirological    cases,   i. 

305. 
Potassium  ferroeyanid  test  for  albumin,  i.  77. 
Potassium  salts,  uremia  and,  i.  440. 
Potash  and  niter  mixture,  ii.  370. 
Poultices,  anodyne,  ii.  Oil. 

ice  bags  and,  in  bubo,  ii.  500. 
Pregnancy,  gonorrhea  and,  ii.  508. 

movable  kidney  and,  i.  405. 
Prepuce,  i.  08. 

acuminata  in,  ii.  537. 
balanitis  of,  ii.  538. 
chancroid  of,  ii.  535. 
circumcision  of,  ii.  547. 
gonorrhea  and,  ii.  534. 
herpes  of,  ii.  534. 
mucous  patches  on,  ii.  537. 
paraphimosis  of,  ii.  543. 
phimosis  of,  ii.  543. 
posthitis  of,  ii.  538. 

operative  treatment  in  diseases  of,  ii.  540. 
Preston,  i.  3. 

Priapism,  vesiculitis  and,  ii.  657. 
Procidentia  uteri,  hydronephrosis  and,  i.  563. 
Prolapse  of  uterus,  bladder   disturbance  due 
■  to,  ii.  108. 
illustrative  case  of,  ii.  109. 
Prolapse  of  rectum,  vesical  calculus  and,  ii.  87. 
Protospathori,  work  on  urine  by,  i.  2. 
Prostate,  abscess  of,  ii.  265. 
cold  variety  of,  ii.  203. 
discharge  of,  ii.  203. 
etiology  of,  ii.  199. 
illustrative  cases  of,  ii.  202. 
measles  and,  ii.  202. 
neurasthenia  and,  ii.  203. 
operations  on,  ii.  206. 
prognosis  of,  ii.  203. 


Prostate,  abscess  of,  symptoms  of,  ii.  199. 

treatment  of,  ii.  205. 
anatomy  of,  i.  03,  ii.  173. 
anomalies  of,  ii.   17(). 
blood  supply  of,  i.  07. 
calculus  of,  diagnosis  of,  ii.  187. 

radiography  in,  ii.   188. 

varieties  of,  ii.   185. 
enlarged,  oystosco])y  and,  i.  210. 

enucleation  of,  ii.  284. 

micturition  and,  ii.  40. 
examination  of,  ii.  173. 
hematuria  and,  i.  279. 
injuries  of,  etiology  of,  ii.  178. 

prognosis  of,  ii.   179. 

symptoms  of,  ii.   178. 

treatment  of,  ii.  179. 
instruments  used  in  operations  upon,  ii.  274. 
lymphatics  of,  i.  07. 
malignant  gi'owth  of,  diagnosis  of,  ii.  271. 

etiology  of,  ii.  268. 

Gibson's  operation  for,  ii.  306. 

illustrative  cases  of,  ii.  272. 

pathological  anatomy  of,  ii.  268. 

prognosis  in,  ii.  270. 

symptoms  of,  ii.  209. 

treatment  of,  ii.  277. 
massage  of,  i.  316,  ii.  211. 
nerves  of,  i.  67. 
operations  on,  ii.  274. 

preparation  of  patients  for,  ii.  295. 
relations  of,  i.   65. 
structure  of,  i.  65. 
tuberculosis  of,  atrophy  and,  ii.  267. 

etiology  of,  ii.  220. 

examination  and  diagnosis  of,  ii.  223. 

pathological  anatomy  of,  ii.  221. 

prognosis  in,  ii.  225. 

symptoms  of,  ii.  223. 

treatment  of,  ii.  225. 
vesicles  and,  examination  of.  i.  314. 
Prostatectomy,  after-treatment  of,  ii.  300. 
Alexander  operation  in,  ii.  288. 
choice  of  method  in,  ii.  293. 
chromic  gut  in,  ii.  305. 
complications  during  and  after,  ii.  302. 
conclusions  upon,  ii.  301. 
epididymitis  and,  ii.  303. 
Fuller's  operation  in,  ii.  291. 
Goodfellow's  operation  in,  ii.  288. 
Guiteras's  recto-vesical,  ii.  292. 
hemorrhage   in,   ii.    302. 
history  of,  ii.  280. 

infrapubic    or    i^erineal    intrauretliral,    ii. 
288. 


INDEX 


689 


Prostatectomy,  kidney  and  stomach  stimula- 
tion after,  11.  301. 

Lillentlial's  two-stage  operation  in,  ii.  305. 

McGill's  operation  in,  ii.  291. 

pericystitis   and,   ii.   302. 

prostatotomy  and,  ii.   155. 

results  of,  ii.  305. 

sexual  function  and,  ii.  293. 

shock  after,  ii.  302. 

suprapubic,  ii.  291,  293. 
technique  of,   ii.  290. 

tympanites  after,  ii.  304. 

urinary  control  after,  ii.  293. 

vomiting  and  distension  after,  ii.  303. 

Watson   and   Cunningham  operation   in,   ii. 
288. 

Young's  perineal,  11.  281. 

Zuckerl-candl's  operation  in,  ii.  281. 
Prostatic  age,  ii.  235. 
Prostatic  atropliy,  calculi   and,   ii.   201. 

castration  and,   11.   207. 

follicular  prostatitis  and,  ii.  204. 

forms  of,  ii.  200. 

Illustrative  cases   of,   11.   202   et  seq. 

pathology  of,  11.  201. 

symptoms  of,  11.  202. 

treatment  of,  11.   207. 

tuberculosis  and,  11.  207. 
Prostatic  calculus,  course  of,  11.  180. 

hour-glass  form  of,  11.  180. 

symptoms   of,  ii.   180. 
Prostatic  cysts,  congenital,  ii.  181. 

diagnosis  of,  11.  182. 

illustrative  case  of,  11.   183. 

retention  and,  11.   181. 

symptoms  of,  11.   181. 

treatment  of,  ii.  184. 

varieties  of,  11.  181. 
Prostatic  douche,  ii.  212. 
Prostatic  epithella,  1.  104. 
Prostatic  hypertrophy,  aspiration  in,  11.   253. 

bladder  changes   due  to,  11.   230. 

burning  on  urination  in,  11.  230. 

calculus  and,  11.  245. 

catheter  life  In,  11.  250. 

climate  and,  11.  250. 

cystitis  and,  11.  53. 

cystoscopy  in,   11.  243. 

differentiation  of,  11.   244. 

diluents  and  diuretics  in,  11.  248. 

dJ^suria  in,  ii.  237. 

encapsulated  or  adenomatous,  ii.  230. 

etiology  of,  11.  220. 

examination   and  diagnosis   of,    ii.   239. 

frequency  of  urination  in,  increased,  ii.  235. 


Prostatic  hypertropliy,  frequency  of  urination 
in,  night,  11.  230. 
kidney  examination  in,  ii.  243. 
micturition   and,  1.   243. 
nonencapsulated  form   of,   ii.   232. 
])areneliymatous  prostatitis  and,  ii.  247. 
patliology  of,  1,  220. 
preprostiitic   stage   of,   ii.   234. 
residual   urine  in,  11.   242. 
retention  of  urine  due   to,   i.  238,   258. 
strictures   and,  11.  240. 
suprapubic   cystotomy   for   drainage   in,   ii. 

1.54. 
symptoms  of,  ii.  234. 
treatment  of,  local,  11.  250. 
nonoperative,  11.  247. 
operative,  ii.  274. 

Bottini  operation,  ii.  275. 
Chetwood  operation,  ii.  279. 
prostatectomy,  11.  281. 
palliative,  ii.  247. 
tumors  and,   11.  247. 
of  bladder,   ii.   09. 
urethra   and,  ii.   229. 
Wallace  on,   ii.  232. 
Prostatic  incisor,  11.  275. 
Prostatic   tractor,   ii.   283. 
Prostatitis,  acute,  treatment  of,  ii.  204. 
acute    parenchymatous,    treatment    of,    11. 

205. 
chronic,  1.   127. 

bathing  and  exercise  for,  ii.  217. 
dilatation  in,  11.  210. 
douche  in,  11.   212. 
etiology  of,  11.  200. 
exacerbations  of,  ii.  208. 
gonococcl  and,  11.  208. 
Impotence  in,  ii.  208. 
Instillations   in,   11.   214. 
irrigation  for,  ii.  211. 
massage  in,  11.  211. 
neurasthenia  in,  ii.  208. 
nocturnal  pollution  in,  ii.  208. 
pathology   of,    ii.   207. 
prostatorrhea   in,   ii.    207,    208. 
recto-prostatic  douche  in,  ii.  214. 
sexual  excesses   and,  ii.  207. 
symptoms  of,   11.   207. 
treatment  of,  ii.  209. 
internal,  ii.  210. 
local,  ii.  210. 

records  important  in,  11.  209. 
urethritis,  chronic,  and,  ii.  214. 
follicular,  atrophy  and,  ii.  204. 
treatment  of,  ii.   204. 


690 


INDEX 


Prostatitis,  follicular,  urethral   condition   in, 
ii.  2G5. 
follicular  and  parenchymatous,  ii.  191. 
complications   of,  ii.   107. 
Cowperitis  and,  ii.  107. 
cystitis   and,   ii.   107. 
diagnosis  of,  ii.   107. 
etiology  of,  ii.    101. 
hypertrophy  and,  ii.  197. 
infections  and,  ii.   192. 
pathology  of,  ii.  192. 
prognosis  of,  ii.   198. 
symptoms   of,   ii.    195. 
urethritis  and,  ii.  197. 
vesiculitis  and,  ii.  197. 
micturition  in,  i.  242. 
parenchymatous,  ii.  207. 
rectal  psychrophore  and,  ii.  219. 
subacute  or  catarrhal,  ii.   190. 
treatment  of,  ii.  204, 
Prostatome,  ii.  275. 
Prostatorrhea,  i.   120. 
diagnosis  of,  ii.  218. 
douche   for,    ii.    213. 
etiology   of,  ii.    217. 
functional  impotence  and,  ii.  218. 
pathology  of,  ii.  217. 
symptoms  of,  ii.  218. 
treatment  of,  ii.  219. 
urethritis  and,   ii.   362. 
Prostatotomy,  perineal,  ii.  106. 
Protargol,  ii.  379. 
Proteus  vulgaris,  i.  115. 
Protozoa   in  blood,  i.   136. 
Pruritus,  scrotal,  ii.  564. 
Pseudo-elephantiosis   of    scrotum,    ii.    570. 
Pseudo-traumatic   hydronephrosis,   i.    392. 
Psoas    abscess,    perinephritic    abscess    and,    i. 

472. 
Psoriasis   vulgaris,   lues   and,   ii.    G82. 
Psychrophores,  i.  346,  ii.  219. 
Pubo-prostatic  ligaments,  i.   48. 
Pudic  artery,  internal,  i.  31. 
Pudic  nerve,  internal,  i.  32. 
Pulse  and  temperature   in   diagnosis   of   uro- 

logical  cases,  i.  306. 
Purdy  electric  centrifuge,  i.  93. 
Purges,  i.  337. 

Pus,  Donne's  test  for,  i.  2S3. 
in  urinary  sediment,  i.  99. 
Pus  casts,  i.  107. 
Pyelitis,  diagnosis  of,  i.  456. 
etiology  of,  i.  453. 
examination  in,  i.  455. 
gonorrheal,  i.  463. 


Pyelitis,  pathology  of,  i.  455. 

prognosis  in,  i.  456. 

symptoms  of,  i.  455. 

treatment  of,   i.   403. 
Pyelo-nephritis,  etiologj-^  of,  i.  456. 

examination  in,  i.  459. 

malaria  and,  i.  459. 

pathology   of,   i.   457. 

radiography  and,  i.  459. 

symptoms  of,  i.  458. 

treatment  of,  i.  463. 
Pyeloplication,   in  hydronephrosis,  i.  569. 
Pyelotomy,  i.   515,  583. 
Pyknometer,   i.  75. 
Pyocyaneus  bacillus,  i.   115. 
Pyonephrosis,   diagnosis  in,  i.  462. 

etiology  of,  i.  460. 

examination  in,  i.  462. 

pathology  of,  i.  461. 

sjTiiptoms   of,   i.  401. 

treatment  of,  i.  463. 

tuberculosis  and,  i..  460. 
Pyosalpinx,  ii.  504. 
Pyramids  of  Ferrein,  i.  37. 

of  Malpighi,  i.  37. 
Pyuria,  cystitis  and,  ii.  41. 

differential  diagnosis  of,   i.  281. 

kidney  disease  and,   i.   369. 

localization  of,  i.  283. 

nephrolithiasis  and,  i.  507. 

Padiography,  in  kidney  disease,  i.   375. 

in  nephrolithiasis,   i.   509. 

in   pyelo-nephritis,   i.    459. 

in  vesical  calculus,  ii.   89. 
Eecords,  i.  322. 

Eectal  gonorrhea  in  female,  ii.   508. 
Rectal  irrigations,  i.  341. 
Rectal  triangle,  i.  25. 
Recto-prostatic  douche,   ii.  214. 
Rectum,  examination  by,  i.   315. 
Reflecting  condenser,  i.   123. 
Renal  artery,  i.  39. 

anomalies  of,  i.  388. 
Renal  colic,   i.   505. 

Renal  disease.     See  Kidney,  Disease  of. 
Renal  epithelia  in  urine,  i.   102. 
Respiration,  i.  307. 
Respiratory  tract,  lues  and,  ii.  694. 
Rete  testes,  i.  59. 
Retention   of  urine,   i.   255. 

anuria  distinguished  from,  i.  259. 

causes  of,  i.  256. 

chronic    complete    and    incomplete,    due   to 
paralysis   or  obstruction,   i.   265. 


INDEX 


691 


Retention  of  urine,  classification  of,  i.  2GG. 

diagnosis  of,  i.  259. 

in  prostatic  trouble,  i.  200. 

niplurc  of  the  bladder  distinguislied  from, 
i.   259. 

symptoms  of,  i,  257. 

treatment  of,  i.  260. 
Retinitis,  uremia  and,  i.  448. 
Rhabdomyoma  of   kidney,   i.   484. 
Rheumatism  in  orchitis,  ii.   010. 
Rliinitis,  luetic,  treatment  of,  ii.   713. 
Rice's  solution  in  estimation  of  urea,  i.  83. 
Ringer's  solution,  i.   347. 
Robert's  method  for  sugar  in  urine,  i.  81. 
Rochester   sterilizer,   i.    154. 
Roentgen  and  X-ray,  i.  7. 
Roulle,  i.  3. 
Rubber  gloves,  i.   157. 
Rubber  tissue,  i.  142. 
Ruhemann's  uricometer,  i.  85. 
Rupia,  luetic,   ii.   686. 
Rupture  of   bladder,   ii.  20. 

of  urethra,  repair  of,  ii.  472. 

Saccliarometers,  i.  82. 

Sago  bodies,  i.  110,  317. 

Salads  in  diet  in  urological  cases,  i.  326. 

Salernian  School,  i.  2. 

Salicylates  in  cystitis,  ii.  47. 

Saline  infusion,  i.  346. 

Salo-santal,  ii.  371. 

Salpingitis,  gonococcal,    ii.   508,   512. 

micturition  and,   i.   245. 
Salpingo-oophoritis,   ii.   504. 
Salvarsan,  action  of,  ii.  718. 
bad  results   from,  ii.   719. 
contraindications  for,  ii.  719. 
dosage  of,  ii.  715. 
epilepsy  and,   ii.  719. 
hematuria  from,  ii.  718. 
intramuscular    injections    of,    in    alkaline 
solution,  ii.  710. 
of  suspension  of  salvarsan  in  iodipin,  ii. 

717. 
technique  of,  ii.  717. 
intravenous  injection  of,  ii.  715. 
iodipin    suspension    of,    for    intramuscular 

injection,  ii.  717. 
leucocytosis  from,  ii.  718. 
optic  nerve  atrophy  and,  ii.   719. 
pain  after,  ii.  718. 

preparation  of,    for   intramuscular   use,   ii. 
717. 
for  intravenous  use,  ii.  716. 
reaction  after,  ii.   718. 


Salvarsan,  results  of,  ii.  719. 
sweating  after,  ii.  718. 
value  of,  ii.  719. 

Wassermann   reaction  and,   ii.   719. 
Sandalwood  oil,   ii.  371. 
emulsion  of,  ii.  373. 
urethritis  and,  ii.  390. 
Santorini,  plexus  of,  i.  00. 
Sarcoma  of  kidney,  i.  483. 
of  penis,  ii.  534. 

of   testis    and    epididymis,    etiology    of,    ii. 
629. 
pathology    of,   ii.   029. 
symptoms  of,  ii.   030. 
treatment   of,   ii.   030. 
of   uterus,    bladder    disturbance   due   to,    ii. 
113. 
Saxe's  pyknometer,  i.  75. 
Scabies  of  penis,  ii.  524. 
Scarlatinous  nephritis,  i.  421. 
Schering-Glatz's  formaldehyd  sterilizer,  i.  155. 
Schule,  i.  3. 

Scirrhous  cancer  of  penis,  ii.  529. 
Scotch  douche,  i.  345. 
Scrotum,  i.  57. 

dermatitis  of,  ii.  563. 
eczema  of,  ii.  563. 
elephantiasis    of,   ii.    568. 
erysipelas  of,  ii.  565. 
gangrene  of,  ii.  565. 

spontaneous,   ii.   566. 
Guiteras's  operation  on,  ii.  572. 
intertrigo  of,  ii.  564. 
lymph,  ii.  568. 
pediculosis  of,  ii.  565. 
pruritus  of,  ii.  564. 
sebaceous  cj^sts  of,  ii.  565. 
septum  of,  i.  57. 
Scudmore,  i.  4. 
Sea  baths,  i.  345. 
Sebaceous  cysts,  scrotal,  ii.  565. 
Seminal    vesicles,    anatomical    considerations 
of,   ii.  646. 
anomalies  of,  ii.  648. 
concretions  of,  ii.   650. 
dilatations  and  cysts  of,   ii.   649. 
epithelia  from,   i.    103. 
inflammation  of,  ii.  651.     See  also  Seminal 

Vesiculitis, 
injuries  of,  ii.  648. 
operations  on : 

Duval's  perineal  vesiculotomy,  ii.  671. 
Fuller's   operation,   ii.    6G9. 
"  total   extirpation   of   genital   tract,"   ii. 
673. 


692 


INDEX 


Seminal  vesicles,  operations  on: 
vesiculectomy,  ii.  673. 
vesiculotomy,  ii.  669. 

syphilis  of,  ii.  648. 

tuberculosis  of,  etiology  of,  ii.  665. 
examination  in,  ii.  660. 
illustrative  case  of,  ii.  660. 
impotence  and,  ii.  665. 
pathology  of,  ii.  665. 
symptoms   and   diagnosis   of,   ii.   666. 
treatment  of,  ii.  667. 

tumors  of,  ii.  648. 
Seminal  vesiculitis,  ii.  651. 

acute,  ii.  652. 

"  chordee  of  the  bladder  "  and,  ii.  652. 

chronic,  i.  130,  ii.  656,  659,  060. 

complications  of,  ii.  653. 

course  of,  ii.  653. 

differential  diagnosis  of,  ii.  655. 

etiology  of,  ii.  651. 

examination  and  diagnosis  of,  ii.  654. 

hernia  and,  ii.   661. 

illustrative  cases  of,  ii.  661,  664. 

impotence  from,  ii.  657. 

massage  in,  ii.  663. 

micturition  and,  i.  244. 

neurasthenia  and,  ii.  657. 

pathology  of,  ii.  651. 

perivesiculitis  and,  ii.  654. 

prostatitis  and,  ii.  660. 

spermatorrhea  and,  ii.  656. 

stricture  and,  ii.  660. 

suppuration  in,  ii.  664. 

symptoms  of  acute,  ii.   652. 

treatment  of  acute,  ii.  662. 

urethritis  and,  ii.  655,  600. 

varicocele   and,   ii.   001. 
Seminiferous  tubules,  i.  59. 
Septicemia,  i.   134. 
Septicemia    and    pyemia,   gonorrhea    and,    ii. 

516. 
Septum   scroti,   i.   57. 
Serous  cysts  of  kidney,  i.  492. 
Serum  albumin  in  urine,  i.  76,  77. 
Sexual  excesses,  prostatitis  and,  ii.  207. 
Sexual  function,  prostatectomy  and,  ii.  293. 
Sexual  intercourse,  lues  and,  ii.  721. 
Sexual  neurasthenia,  vesiculitis  and,  ii.   658. 
Shellfish  in  diet  of  urological  cases,  i.  325. 
Shock,  kidney  injuries  and,  i.  393. 
Shreds  in  urine,  i.   109,  ii.  358. 
Sigmoiditis,   pericystitis   and,   ii.   43. 
Silver  nitrate  test  for  chlorids,  i.  90. 
Silver  salts  in  urethritis,  ii.  379. 
Silver  solutions  in  urethritis,  ii.  388. 


Simon,  first  nephrectomy  by,  i.  4. 

Sinus  pocularis,  i.  54. 

Sinuses,  after  nephrotomy,  i.  597. 

Siphonage  after  operation,  ii.  162. 

Sitz  baths,  i.  345. 

"606."     See  Salvarsan. 

Skatol,  i.  87. 

Skeleton,  in  relation  to  genito-urinary  tract, 

i.  10. 
Skene's  glands,  i.   50. 
Skin  in  diagnosis,  i.  304. 
Skins  in  urine,  i.   110. 
Smallpox,  and  orchitis,  ii.  609. 
Smegma,  i.   68. 
Smegma  bacillus,  tuberculosis  of  kidney  and, 

i.  538. 
Smegma  and  tubercle  bacillus,  differentiated, 

i.   113. 
Snell's  formalin  sterilizer,  i.  157. 
"Snowflakes,"  i.   109,  110,  318. 
Soft  diet  in  urological  cases,  i.  327. 
Sounds,   i.   176,  ii.  429. 
Benique,  i.  179,  180. 
curves  of,  i.   176. 
metallic,   ii.   6. 
passing  of,  French  method  of,  i.  180. 

technique  of,  i.   177. 
scale  of,  i.   176. 
Southey's  drainage  tubes,  i.  437. 
Spagiric  method  of  diagnosis,  i.  2. 
Spanish-Americans,    urinary    diseases    of,    i. 

299. 
Spasmodic  stricture,  tumors   of  bladder  and, 

ii.   65. 
Specific  or  gonococcal  urethritis,  i.   125. 
Spermatic  artery,  i.  60. 
Spermatic  cord,  i.  60,  ii.  637. 
cysts  of,  dermoid,  ii.  639. 
encysted  hydroceles  of,  ii.  639. 
hematocele  of,  etiology  of,  ii.  637. 
pathology  of,  ii.  637. 
symptoms  of,  ii.  638. 
treatment  of,  ii.  638. 
inflammation  of,  gonococcal,  ii.  039. 
phlegmonous,   ii.    639. 
serous,  ii.   640. 
suppurative,  ii.  640. 
lues  of,  ii.  641. 

tuberculosis  of,  diagnosis  of,  ii.  640. 
illustrative  cases  of,  ii.  641. 
pathology  of,  ii.   640. 
symptoms  of,  ii.  640. 
treatment  of,  ii.  640. 
tumors,  ii.  638. 
varicocele  and,  ii.  641. 


INDEX 


693 


Rpormatic   vein,   i.    60. 

iSpormatocelc,  ii.  58;i. 

ypcrmatorrliea,  urethritis  and,  ii,  362. 

Spermatozoa,  i.  318. 

Sphincter  ani,  i.  27. 

Spica  bandage,  ii.  557,  559. 

Spinal   anesthesia,   i.  352. 

Spinal  lesions,  retention  of  urine   due  to,   i. 

256. 
Spinal  sclerosis,  cathcteral  indication  of,  ii.  5. 
Spirocheta   pallida,   i.    121. 
demonstration  of,  i.  122. 
Sponge  baths,  i.  346. 
Sponges,  i.   142. 
Spontaneous  gangrene,  ii.  566. 
Stammering,  urinary,  i.  254. 
Staphylococcus  pyogenes  albus,  i.   115. 

in  blood,  i.   135. 
Staphylococcus  pyogenes  aureus,  i.  114. 
Steam,  sterilization  by,  i.   154. 
Sterility,  spididymitis   and,  ii.   607. 
female,  gonorrhea  and,  ii.  509. 
Martin's  operation  for,  ii.   615. 
Sterilization  and  disinfection,  detailed  meth- 
ods of,  i.  156, 
Sterilization  of  instruments  and  apparatus,  i. 

153. 
Stomatoscope,  the,  i.   199. 
Stone.     See  Calculus. 

frequent   micturition   and,   ii.    40. 
in  bladder.     See  Vesical  Calculus, 
tuberculosis  and,  ii.   101. 
tumor  of  bladder  and,  ii.   69,   106. 
Stone  searcher,  Thompson's,   ii.  6. 
Stout's  stricturectomy,  ii.  471. 
Streptococcus   pyogenes,   i.    114. 

in  blood,  i.   135. 
Stricture  of  urethra.     See  Urethra,  Stricture 
of. 
complete   excision   of,   ii.   470. 
cystoscojjy  in,    i.   216. 
dilatation  of,  ii.  392. 
electrolytic   cure   of,    ii.   468. 
micturition  and,    i.   243. 
resection  and  excision  of,  ii.  469, 
Stricture  of  meatus,  ii,  418. 

tuberculosis  of  the  bladder  and,  ii.   95. 
Stricture  of  meatus  or  fossa  navicularis,  cys- 
titis from,  ii.  53. 
Stricture   of  ureter,  ureterotomy   for,  i.   655. 
Stricturectomy,  Stout  method,  ii.  471. 
Struma  lipomatodes  aberrantaj  renis,  i,  484. 
Sugar  in  urine,  i.   79. 

fermentation  test  for,  i.  81. 
precautions  in  testing  for,  i,  81. 


Sugar  in  urine,  qualitative  tests  for,  i,  79, 

quantitative  tests  for,  i.  81, 
Sugar  granules,   i,    110,   318. 
Sulphates   in  urinary   sediment,   i,   97. 

in  urine,  i.  91. 
Suspensory  ligament  of  penis,  i,  69, 
Suprapubic  cystotomy,  ii.   144. 
Suprapubic  lithotomy,  ii.  150. 
Suprapubic   pain,  i.   302. 
Swabs  for  urethral  treatments,  ii.  398. 
Sweets    and    desserts    in    diet    of    urological 

cases,   i.  326. 
Symptoms,  general,  in  diagnosis  of  cases: 

behavior,  general,  i.  306. 

nutrition,  i.  304. 

odor,  i.  305. 

posture,  i.  305. 

pulse  and  temperature,  i.  306. 

respiration,  i.  307. 

skin,  i.  304. 

tongue,  i.  306. 
Synorchism,  ii,  587, 
Syphilis,     See  Lues, 
Syphilitic   urethritis,  i.    121,  ii.   407. 
Syringe   for   local  anesthesia,   i.  354. 
Syringes,  sterilization  of,  i.   159. 
Systemic  infections,  gonorrhea  and,  ii.  516. 

Tabes,  ii.  699. 

Table,   examining,  i.    145. 

portable,  for  cystoscopy,  i.  211. 
Table  waters,  i.  339. 
"Tapioca,"  i.  109. 

Tenesmus,  tuberculosis  of  kidney  and,  i.  535. 
Teratoma  of  testis,  ii.  633. 
Tertiary  lesions,  preputial,  ii.  537. 
Testicle.     See  Testis. 
Testis,  i.  58. 

abdominal  retention  of,  ii.  589. 

absence  of,  ii.  586. 

anatomical    changes    due    to    anomalies    of 

migration  of,  ii.  593. 
anomalies  of,  ii.  586. 

complications  of,  ii,  594, 
developmental,  ii,  586. 
illustrative  cases  of,  ii,  590,  592. 
migrational,  ii.  588. 
nutritional,  ii,  587. 
of  adnexa,  ii.  599. 
artificial,  ii.  589,  599. 
atrophy  of,  ii.   587. 
blood  siipply  of,  i.  60. 
contusions   of,   ii.   601. 
coverings  of,  i.  61. 
ectopia  of,  ii.  591. 


694 


INDEX 


Testis,  ectopia  of,  crural,  ii,  591. 

perineal,  ii.  591. 

pubo-penile,   ii.   593. 
examination  of,  i.  312. 
fusion    of,  ii.   587. 
hypertrophy  of,  ii.   587. 
inCammation   of,  ii.   603. 
injuries  of: 

contusions,  ii.  601. 

luxation,  ii.  599. 

torsion,  ii.  603. 

wounds,  ii.  602. 
inversion   of,   ii.   593. 
irritable,   ii.   634. 
lues  and,  ii.  693,  694. 
luxation  of,  ii.  599. 

illustrative   case    of,    ii.    600. 

treatment  of,  ii.  601. 
misplaced,  operation  for,  ii.  595. 
neuralgia  of,  ii.  634. 
retention  of,  cruro-scrotal,  ii.  590. 

etiology  if,  ii.  588. 

iliac,   ii.   590. 

inguinal,  ii.   590. 

transitional,  ii.  590. 

treatment  of,  ii.   594. 

varieties  of,  ii.  589. 
structure  of,  i.  59. 
supernumerary,  ii.   586. 
torsion  of,  ii.  603. 
tuberculosis  of,  diagnosis  of,  ii.  621. 

epidectomy  for,   ii.   623. 

etiology  of,  ii.  618. 

gonorrhea   and,   ii.  621. 

gummatous  epididymitis  and,  ii.  621. 

malignancy  and,  ii.  621. 

pathology   of,  ii.    618. 

predisposing  causes  of,  ii.  618. 

prognosis  of,  ii.  622. 

symptoms  of,  ii.  619. 

syphilis  and,   ii.   621. 

treatment  of,  ii.  622. 

wounds  of,  ii.  602. 
Testis  and  epididyiaitis,  syphilis  of,  ii.  624. 
tumors  and  cysts  of: 

carcinoma,  ii.  627. 

enchondroma,  ii.  631. 

fibroma,  ii.  632. 

fungus   or  hernia,  ii.   633. 

lymphadenoma,  ii.  632. 

myxoma,  ii.  633. 

osteoma,  ii.  633. 

sarcoma,  ii.  629. 

teratoma,  ii.  633. 
Therapeutics,  urological,  i.  323. 


Thompson,    Sir  Henry,  quoted   on   strictures, 

ii.    420. 
Thompson  lithotrite,  ii.  134. 

stone  searcher,  ii.  6. 
Thorn   apple    crystals,   i.   95. 
Tinea  tricliophytina  cruris,  ii.  564. 
Tobacco   poultice,   ii.   611. 
Tongue   in   diagnosis   of   urological   cases,   i. 

306. 
Tonics  in  cystitis,   ii.   48. 
Tousson's  case  of  single  kidney,  i.  622. 
Towels   in   office   dressing   equipment,   i.    142, 

158. 
"'  Toxemia  and  autointoxication,"  i.  361. 
Toxic  glycosuria,   i.   365. 
Trabeculation  of  bladder,  i.  223. 
Tragacanth  as  a  lubricant,   i.   161. 
Transluceney  test,  hydrocele  and,  ii.  577. 
Transversus  perinei  muscle,  i.  27. 
Traumatic  urethritis,  ii.  408. 
Trendelenburg     operation     of     uretero-pyelo- 
plasty,  i.   620. 
position,   ii.    147. 
Treponema  pallida,  i.   121. 
Triangular  ligament,  i.  28. 
Trichloracetic  acid  test  for  albumin,  i.  77. 
Trigone,  i.  50,  51. 

cystoscopic  appearance  of,  i.  221. 
Trigonitis,  ii.  508. 

Triple  dose  in  gonococcal  urethritis,  ii.  375. 
Triple  phosphate  crystals,  i.  97. 
Tubercle  bacillus   in  blood,  i.    135. 
in  urine,  i.   112. 

kidney  tuberculosis  and,  i.  538. 
Tubercular  adenitis,  ii.  558. 
Tubercular  urethritis,  i.   121. 
Tuberculin  test,  i.  539. 
Tuberculosis,  leucocyte  count  in,  i.  134. 
of  bladder,  i.   224. 

anesthesia  necessary  in  examining  for,  ii. 
100. 

"  B.  and  B.  Mixture  "  for  pain  in,  ii.  103. 

cystoscopic  examination  for,  ii.  100. 

differentiation   of,  ii.    101. 

etiology  of,  ii.  95. 

frequent  urination  in,  ii.  98. 

gonorrhea  and,  ii.  96. 

gonorrheal  cystitis  and,  ii.  102. 

hematuria  in,  ii.  99. 

incontinence  from,  i.  268. 

inoculation  in,  ii.  100. 

micturition  and,  i.  241. 

pain  in,  ii.  99. 

pathology   of,  ii.   97. 

prostatic  enlargement  and,  ii.  101. 


INDEX 


695 


Tuberculosis,  of  bladder,  stricture  and,  ii.  101. 

symptoms    and    diagnosis   of,    ii.    08. 

treatment  of,  ii.  102. 
local,  ii.   104. 
medical,  ii.   103. 
operative,  ii.  104. 

tumors  of  bladder  and,  ii.  60. 

urinary  findings  in,  ii.  !)!). 
of  kidney.     See  Kidney,  Tuberculosis  of. 

nephrolithia:,:s  and,  i.  511. 

nephrostomy  in,  i.  546. 

nephrotomy  in,  i.  546. 
of  prostate.     See  Prostate,  Tuberculosis  of, 
of  seminal  vesicles,  ii.  065. 
of  spermatic  cord,  ii.  640. 
of  urethra.     See  Urethra,  Tuberculosis  of. 
penis   and,  ii.   525. 
pyonephrosis  and,   i.  460. 
Tuberculous  kidney,  hematuria   and,  i.   280. 

ureteral   ulcers  in,   i.  374. 
Tuberculous     peritonitis,     bladder,     enlarged, 

and,  ii.  2. 
Tubuli  recti  in  testis,  i.   50. 
Tumors,  bladder  disturbances  due  to,  ii.   110. 
of  bladder,  i.  225,  ii.  58. 

Bilharzia   infection    and,    ii.   59. 

cauliflower  growth  of,   ii.   62. 

complications  of,  ii.  67,  72. 

course  of,  ii.  67. 

cystectomy  in,  partial,  ii.  76. 

cystitis  and,  ii.  53. 

cystoscopy   in,    ii.   68. 

diagnosis  of,  ii.   67. 

differential  diagnosis  of,   ii.  69. 

disturbances    of    micturition    due   to,    ii. 
66. 

etiology  of,  ii.  58. 

examination  for,  ii.  68. 

exploratory  incision  in,   ii.  69. 

fulguration  of,  ii.  75. 

hematuria  and,   ii.  64,   66. 

hemorrhage   in,   treatment   of,   ii.   70. 

histology  and  pathology  of,  ii.  59. 

illustrative  cases  of,  ii.  65. 

infection   in,   ii.   72. 

mictui'ition  and,  i.  241. 

multiple,  ii.  61. 

nephrostomy  in,  ii.  77. 

occurrence  of,   ii.   58. 

operating  cystoscope  in,  ii.  74. 

pain   from,  ii.    66. 
treatment  of,  ii.   71. 

palpation  of,   ii.  69. 

pedunculated,   ii.    63. 

perineal  cystotomy   incision  for,  ii.    168. 


Tumors,   of   bladder,   primary   and   secondary 
forms  of,  ii.   61. 
prognosis  in,  ii.  69. 
prostatic  hypertrophy  and,  ii.  69. 
removal  of,  ii.   152. 

by  female  urethra,  ii.   74. 
by  perineal  route,  ii.  74. 
by  vagino-vesical  incision,  ii.  74. 
cndovesical,  ii,  74. 
secondary  changes  due  to,  ii.   64. 
shrivelling  of,   ii.    76. 
stone  and,  ii.  69. 
suprapubic  cystotomy  in,  ii.  75. 
symptoms  of,  ii.  64. 
total  extirpation  of  bladder  in,  ii.  76. 
treatment  of,  ii.  70. 
operative,  ii.   73. 
palliative,  ii.  70. 
tuberculosis    and,    ii.    69,    101. 
villous,   ii.  62. 
of  kidney.     See  Kidney,  Tumors  of. 
of  pelvis,   micturition  and,   i.   245. 
of  penis,   ii.   527. 
Tunica  albuginea  in  testis,   i.  59. 
Tunica  vaginalis,  i.  58,  59. 
Tympanitis,   kidney  injury  and,  i.   394. 

prostatectomy   and,   ii.   304. 
Typhoid  bacillus  in  blood,  i.   136. 
Typhoid  fever,  orchitis  and,  ii.  609. 
Tyrosin  and  leucin  in  urinary  sediment,  i.  97. 
Tyrosin  in  urine,  i.  89. 

Ulcers  of  bladder,  i.  224,  ii.  55. 

complications  of,  ii.  56. 

curetting  of,   ii.   142. 

diagnosis  of,   ii.   56. 

etiology   of,   ii.  55. 

illustrative  cases  of,  ii.  56. 

pathological  anatomy  of,  ii.  55. 

prognosis  in,  ji.  56. 

symptoms  and  course  of,  ii.  55. 

treatment  of,  ii.  56. 
Ultzmann,   instillator,  i.    174. 
Ultzmann's  test  for  phosphates,  i.  90. 
Urachus,  i.  45,  48. 

vesical  fissure  and,  ii.  17. 
Urge,  Micrococcus,  i.   115. 
Urates,  i.  86. 

in  sediment  of  urine,  i.  95. 

in  urine,  i.  282. 
Urea,  discovery  of,  i.  3. 

compoimds  of,  i.   83. 

quantitative  estimation  of,  i.  83. 
Uremia,  i.  440. 

acute  form  of    i.  442. 


696 


INDEX 


Uremia,  acute  prolonged,  i.  449. 
ammonia  in,  i.  452. 
cerebral   hemorrhage   and,   i.   448,    450. 
chronic,  i.   443. 
death  in,  cause  of,  i.  451. 
diagnosis  of,  i.  447. 
differential  diagnosis  of,  i.  448,  450. 
epilepsy  and,   i.   448,   450. 
etiology  of,  i.  440. 
intoxications   and,   i.   448,  450. 
latent  or  mild  form  of,  1.  442. 
meningitis  and,  i.  448,  450. 
prognosis   in,  i.  449. 
retinitis  in,  i.  448. 
symptom-groups  in,  i.  443. 
symptoms  of,  i.  442. 

eye,  i.   446. 

gastro-intestinal,  i.  445. 

general,   i.   447. 

nervous,  i.  444. 

urinary,  i.  446. 
treatment  of,  i.  451. 
venesection  in,  i.  451. 
Ureter,  i.  41. 

accidental  wounds  of,  etiology  of,  i.  625. 

prognosis  in,   1.   625. 

treatment  of,  i.  626. 
anomalies  of,  ii.   622. 

caliber  anomalies,  i.  625. 

deficient    and   supernumerary    ureters,    i. 
622. 

diverticulum,    i.    624. 

intravesical  prolapse,  i.  624. 

positional  anomalies,  i.  623. 
caliber  of,  i.  44. 

catheterization  of.     See  Ureteral  Catheteri- 
zation, 
cathetters  for,  i.  230. 
cysts  of,  i.  632. 

embryology  of,  and  hydronephrosis,  i.  560. 
fistulas  of,  diagnosis  of,  i.  644. 

etiology   of,   i.   643. 

pathology  of,  i.  643. 

prognosis  in,  i.   645. 

symptoms  of,  i.  644. 

treatment  of,  i.  645. 

Watson  operation  for,  i.  645. 
hematuria  and,  i.  280. 
inflammation  of,  etiology  of,  i.  628. 

pathology  of,  i.  629. 

symptoms  of,  i.  630. 

treatment  of,  i.  630. 
injuries   of,   i.   625. 

operative,  diagnosis  of,  i.  627. 
prognosis  in,  i.  627.  . 


Ureter,  injuries  of,  operative,   symptoms  of, 
620. 
movable  kidney  and,  i.  404. 
operations  on,  1.  646. 
pain  in,  i.  302. 

stricture  of,  diagnosis  of,  i.  643. 
etiology  of,  i.   641. 
pathology  of,  i.  642. 
symptoms  of,  i.  642. 
treatment  of,  i.  643. 
structure  of,  i.  44. 
treatment  of,  in  tuberculosis   of  kidney,  i. 

548. 
tuberculosis  of,  diagnosis  of,  i.  641. 
etiology  of,  i.  639. 
examination   of,   i.    641. 
pathology  of,  i.  639. 
prognosis  of,  i.  641. 
symptoms  of,  i.  640. 
treatment  of,  i.  641. 
tuberculous  occlusion  of,  i.  530. 
tumors  of,  etiology  of,  i.  631. 
examination  for,  i.  632. 
pathology  of,  i.  631. 
prognosis   in,   i.    632. 
symptoms  of,  i.  632. 
treatment  of,  i.   632. 
variations   of,   i.   44. 
Ureteral  calculi,  anuria  from,  i.  635- 
character  of,  i.  634. 
diagnosis  of,  i.  634. 
etiology  of,  i.   633. 
symptoms  of,   i.   634. 
treatment  of,  i.  637. 
Ureteral  catheter,  influencing  direction  of,  i. 

202. 
Ureteral  catheterization,  i.  227. 

as   a  therapeutic  procedure,  i.   233. 
comparative  flow  in,  i.  378. 
dangers  and  complications  of,  i.  234. 
diagnostic  value  of,  i.  233. 
first,  i.   4. 
history  of,  i.   199. 

in  diagnosis  of  kidney  disease,  i.  373. 
in  hydronephrosis,  i.  568. 
in  pelvic  operations,  i.  234. 
in  tuberculosis  of  kidney,  i.  540. 
Ureteral  epithelia,  i.   103. 
Ureteral  secretion,  rhythm  of,  i.  232. 
Ureteral  ulcers,  tubercular  kidney  and,  i.  374. 
Ureterectomy,  i.  663. 
Uretero-colostomy,  i.  662. 
Uretero-cystotomy,  extraperitoneal,  i.  661. 
transperitoneal,  i.  660. 
transvesical,  i.  662. 


INDEX 


697 


Uretero-cystotomy,  uretero-vaginal,  i.  6()2. 
Urotero-intestinal    anastomosis,  i.   (>G2. 
Uretoro-lithotomy,  i.  ()4(),  G47. 
Uretero-pydoneostomy,  hydronephrosis  and,  i. 

568. 
Uretcro-pyelophisty,  i.  620. 
Finger's  operation  in,  i.  619. 
Trendelenburg's  operation   in,   i.   620. 
Uretero-ureterostomy,    Bovee's   method    of,    i. 
659. 
Poggi   operation   for,   i.   658. 
Van  Hook's  method  of,  i.  059. 
Ureteroplasty,  hydronephrosis  and,  i.  569. 
Ureterorrhaphy,  i.  657. 
Ureterostomy,   i.  659. 
Ureterotomy,  abdominal,   i.   649. 
complications  of,  1.   655. 
extraperitoneal,  i.  649. 
for  stricture,  i.  655. 
perineal,  i.  653. 
transperitoneal,   i.   652. 
vaginal  route  for,  i.  654. 
vesico-uretero-lithotomy,  i.  655. 
Urethra,  i.   52. 

absence  of,  total,  ii.  311. 
anomalies  of,  ii.  309. 
epispadias,  ii.   320. 
hypospadias,  ii.  314. 
blood  supply  of,  i.   56. 
calculus  of.     See  Urethral  Calculus, 
dilatations  and  diverticula  of,  ii.  313. 
displaced,  ii.   467. 

stricture  and,  ii.  467. 
double,    ii.   312. 
examination  of,  i.  312,  318, 
female,  i.   56. 

fistulas    of,    autoplastic    operation    for,    ii. 
487. 
etiology  of,  ii.  481. 
examination  for,  ii.  483. 
in  pendulous  portion,  ii.  481. 
in  perineo-bulbous  portion,  ii.  481. 
in  scrotal  portion,   ii.   481,  486. 
in  urethro-rectal   portion,  ii.   489. 
in  urethro-vaginal  portion,   ii.   493. 
pathology  of,  ii.   481. 
perineorrhaphy   for,   ii.   488. 
symptoms  of,  ii.  482. 
treatment  of,  ii.  483. 

electrical,  ii.  486,  489. 
urethroplasty  in,   ii.  484. 
urethrorrhaphy  for,  ii.  483. 
follicles  and  glands  of,  ii.  356. 
foreign  bodies  in,  complications  of,  ii.  345. 
diagnosis  of,  ii.  345. 


Urethra,  foreign  bodies  in,  symptoms  of,  ii. 
344. 
treatment  of,  ii.  345. 
hematuria  and,  i.  279. 
imperforate,   ii.   311. 
inflammation  of.     See  Urethritis, 
injuries  of,  ii.  325. 
external,  ii.  325. 

dull  objects  causing,  ii.  327. 
diagnosis  of,  ii.  332. 
etiology    of,    ii.    327. 
pathology  of,  ii.  328. 
prognosis   in,   ii.   332. 
symptoms  of,  ii.  330. 
treatment  of,  ii.  333. 
sharp  instruments  causing,  ii.  325. 
treatment  of,   ii.  326. 
extravasation  of  urine  in,  ii.  330,  335. 
internal,   ii.    334. 
etiology  of,  ii.  334. 
false  passages  due  to,  ii.  337. 
symptoms  of,  ii.  334. 
treatment  of,  ii.   335. 
rupture  of  bladder  and,  ii.  332. 
instruments  used  in  operations  on,  ii.  442. 
irrigations  of,  ii.  383. 
membranous,  i.   54. 
nerve  supply  of,  i.  56. 
normal,   i.    194. 
occlusion  of,  ii.  311. 
penile,   i.   67. 
prostatic,  i.  53. 

prostatic  hypertrophy  and,  ii.  229. 
rupture  of,  pathology  of,   ii.   329. 
repair   in,    ii.    472. 
symptoms  of,  ii.   330. 
spongy  portion  of,  i.  55. 
stricture  of,  ii.   409. 
acquired,   ii.    413. 
Benique  sounds  in,  ii.  430. 
bougies  in,  ii.  430. 
causes  of,  ii.  409. 
complications  of,  ii.  414. 
consistence  of,  ii.  410. 
cystitis  and,  ii.  415,  424. 
differentiation  of,  ii.  423. 
dilatation    of,    ii.    425. 
continuous,  ii.  431. 
treatment  accompanying,  ii.  427. 
disturbance  of  stream  by,  ii.  413. 

of  urination  by,  ii.  414. 
examination  and  diagnosis  of,  ii.  417. 
extravasation   of  urine   in,   ii.  416. 
false  passages  in,  ii.  421. 
filiform,  ii.  420,  431. 


698 


INDEX 


Urethra,  stricture  of,  fistulsE  and,  ii.  416. 

form  of,  ii.  410. 

frequent  urination  from,  ii.  415. 

gleet  in,  ii.  413. 

impassable,  ii.  432. 

infiltrates  and,  ii.  410. 

inflammatory,  ii.  411. 

irritable,  ii.  411. 

Kollmann  dilator  in,  ii.  42G. 

meatotomy   in,   ii.   433. 

meatus  and,  ii.  418. 

movable,   ii.   411. 

Oberliinder  dilator  in,  ii.   426. 

pain  in,  ii.   413. 

pathology'  of,  ii.  411. 

periurethral  abscess  and,  ii.  416. 

pockets  and,  ii.  421,  429. 

position  of,  ii.  410. 

prognosis  in,  ii.  425. 

prostatic  hypertrophy  and,  ii.  423. 

prostatitis  and,  ii.  424. 

retention   from,   ii.   414. 

size   of,  ii.    411.    . 

small   calibered,   ii.   428. 
anterior,  ii.  477. 

spasmodic,  ii.  411,  417. 

illustrative  case  of,  ii.  418. 

symptoms  of,  ii.   412. 

traumatic,  ii.    412. 

treatment  of,  ii.  425. 

tuberculous   cystitis   and,   ii.   424. 

timnel  soimd  in,  ii.  423. 

urethrotomy  in,   ii.  435. 

urine  in,  ii.  416. 

varieties  of,  ii.  410. 

vesiculitis  and,  ii.  425. 
structure  of,   i.   55. 
tuberculosis  of,  etiology  of,  ii.  405. 

pathological  anatomy  of,  ii.  405. 

symptoms   of,   ii.    406. 

treatment  of,  ii.  406. 
Urethral  calculus,  diagnosis  of,  ii.  341. 
etiology  of,  ii.  339. 
in  women,   ii.    343. 
pathology  of,  ii.   339. 
symptoms  of,  ii.   340. 
treatment  of,  ii.   341. 
Urethral   dilators,    i.    182. 
Urethral  epithelia,  i.   104. 
Urethral  fever,  catheter  life  and,  ii.  257. 

prevention   of,   i.    235. 
Urethral  follicles,  i.  196. 
Urethral  hernia  of  bladder,  ii.  32. 
Urethral  knives,   i.    191. 
Urethral  piston  hand  syringe,  ii.  377. 


Urethral  pouches,  ii.  337. 

Urethrectomy,  complete  excision   of   stricture 
by,  ii.  470. 
partial,  ii.  469. 
Urethritis,  catheter  life  and,  ii.  257. 
chancroidal,  i.   124,   ii.  408. 
discharge  in,  ii.  351. 
gonococcal,   acute,   i.    125. 
active  period  of,  ii.  349. 
alcoholic  excesses  and,  ii.  352. 

alkaline    diluents    in,   ii.    370. 

antiseptic  solutions  for,  ii.   378. 

astringents  in,  ii.  380. 

bacteriologj'  of,  ii.  348. 

balsamics  in,  ii.  370. 

bowels  in,  ii.  368. 

bubo  in,  ii.   350. 

butterfly  dressing  in,  ii.  367. 

catheter  irrigations  in,  ii.   3S9. 

chordee  in,  ii.  350,  374. 

chronic  differentiated  from,  ii.  353. 

combination   prescriptions  in,  ii.   372. 

complications   of,   ii.   369. 

cure  in,  ii.  369. 

degrees  of,  ii.  376. 

diagnosis  of,  ii.  352. 

diet  in,   ii.   368. 

differential  diagnosis  of,  ii.  353. 

drinks  in,  ii.  368. 

etiology   of,   ii.   347. 

hyperacute  form  of,  ii.  351,  376. 

incubation  in,  ii.  349. 

inflamed  inguinal  glands  in,  ii.  376. 

irrigations  in,  ii.   383. 
Janet's,  ii.  383. 

Lafayette  mixture  in,  ii.  372. 

lymphatics   in,  ii.   350. 

march  of  gonococcus  in,  ii.  347. 

mercurol  in,  ii.  380. 

mode   of   life  in,   ii.   369. 

moderately  acute   form   of,  ii.   376. 

nonspecific  form  and,   ii.   353. 

pathology  of,  ii.  348. 

phlegmonous,  ii.   351. 

potash  and  niter  mixture  in,  ii.  370. 

prognosis   in,   ii.   353. 

prophylaxis  of,  ii.  363,  369. 

sexual  excitement  and,  ii.  368. 

silver  salts  in,  ii.   379. 

silver   solutions   in,  ii.  388. 

simple  form  of,   ii.   352. 

stage  of  decline  in,  ii.  351. 

statistics  of,  ii.  346. 

subacute  form  of,  ii.  352,  376. 

symptoms   of,    ii.    349. 


INDEX 


699 


Urethritis,   gonococcal,   acute,   symptoms   of, 
according  to  severity,  ii.   351. 
syphilis  and,  ii.  353. 
tobacco  in,  ii.  368. 
toilet  in,  ii.   368. 
treatment  of,  ii.  363. 
abortive,  ii.  365. 
general,  ii.  370. 
hygienic,  ii.  301. 
internal,   ii.   370. 
local  or  direct,  ii.  376. 
nietliodical,  ii.  367. 
radical,   ii.   399. 
supportive,  ii.   301. 
symptomatic,  ii.   301. 
urinary  antiseptics  in,  ii.  372. 
urination  in,  ii.  350. 
urine  in,  ii.  350,  368. 
acute  posterior,  etiology  of,  ii.  354. 
symptoms  of,  ii.  354. 

constitutional,  ii.  355. 
treatment  of,   ii.   389. 
internal,  ii.  390. 

sandalwood  oil  emulsion  in,   ii.   390. 
chronic,  i.  125,  ii.  357. 
bacteria  in,  ii.   358. 
diagnosis  of,  ii.  359. 
differential  diagnosis  of,  ii.  362. 
dilatations  in,  ii.  392. 
dilators   in,   ii.    394. 
discharge  in,  ii.  358. 
endoscopic  medication  of,  ii.  399. 
etiology  of,  ii.  355. 
exacerbation  of,  ii.  391. 
examination  in,  ii.  361. 
hypospadias  and,  ii.  395. 
infiltrations    in,   ii.    361. 
meatotomy  in,  ii.  303. 
pathology  of,  ii.  350. 
prostatorrhea  and,  ii.  362. 
shreds  in  urine  in,  ii.  358. 
spermatorrhea  and,  ii.  362. 
strictures   following,   ii.    392. 
swabs   for,   ii.  398. 
symptoms  of,   ii.   357. 
treatment   of,    ii.    390. 
urethroscope   in,  ii.  396. 
chronic  posterior,  ii.  359. 

treatment  of,  ii.  399. 
marriage  and,  ii.  401. 
micturition   and,   i.   242. 
nonspecific,  i.   121. 

clinical  features  of,   ii.  404. 
etiology   of,   ii.   404. 
treatment  of,  ii.  404. 


Urethritis,  nonspecific,  posterior,  cystitis  and, 
ii.  42. 
syphilitic,  i.   121,  ii.  407. 
traumatic,   ii.   408. 
tuberculous,  i.   121. 
vesiculitis  and,  ii.  655. 
Urethro-lithotomy,  ii.  341. 
Urethro-rectal    fistulas,    etiology   of,    ii.    489. 
examination  for,  ii.  490. 
pathology  of,  ii.  490. 
symptoms  of,  ii.  490. 
treatment  of,  ii.  491. 
Urethro-urethral    end-to-end    anastomosis,    ii. 

473. 
Urethro-vagina]   fistulas,  ii.   493. 
Urethroplasty,   ii.   484. 
Urethrorrhaphy,    ii.    469. 

urethral  fistulas  and,  ii.  483. 
Urethrorrhea  ex  lihidine,  i.   119. 
Urethroscope,  i,  188,  320. 
Buerger,   i.    192. 

contraindicated,  in  acute  conditions,  i.  197. 
Guiteras,  i.  188. 
sterilization  of,  i.   159. 
Swinburne,  i.  191. 
treatment  with,  i.    197. 
urethritis  and,  ii.  396. 
value  of,   i.   197. 
Urethroscopy,    in    pathological    conditions,    i. 
196. 
technique  of,  i.  192. 
Urethrotomy,   ii.   435. 
external,  ii.  440. 

accidents   during,  ii.  462. 
bowels  after,  ii.  465. 
catheter  en  chemise  after,  ii.  466. 
complications  of,  ii.   466. 
cysto-urethrotomy  and,  ii.  458. 
grooved  perineal  cannula  in,  ii.  457. 
hemorrhage  after,   ii.  465. 
hemorrhage   in,   ii.   462. 
milk   leg  after,  ii.   467. 
perineal  section  in,  after-treatment  of,  ii. 
463. 
without  a  guide  in,  ii.  456. 
periurethral   abscess   and,   ii.  468. 
positions   in  operation  in,  ii.  446. 
preparation  of  patient  for,  ii.  440. 
rectum  cut  into  in,  ii.  463. 
retained  catheter  after,  ii.  465. 
sepsis   after,    ii.    466. 
technique  of,   ii.   448. 
temperature  after,  ii.  465. 
urethral  fever  after,  ii.  466. 
external-internal,  ii.  459. 


700 


INDEX 


Urethrotomy,  "  guide  "  in,  ii.  440. 

instruments   for,   ii.  442. 

internal-external,  ii.  459. 

Maisonneuve,  ii.  437. 

preparation  for,  ii.  430,  442. 

technique  of,  ii.  43G. 
Uric  acid,  i.  84. 

discovery  of,  i.  3. 

formation  and  elimination  of,  i.  358. 

qualitative  tests  for,  i.   85. 

quantitative  estimation  of,  i.  85. 
Uric  acid  calculi,  i.  94. 
Uric  acid  diet,  i.   359. 
Uricacidemia,  diet  in,  i.  359. 

etiology  of,  i.  358. 

symptoms  of,  i.  359. 

treatment,  i.  359. 
Uricometer,  i.  85. 

Urinal,  method  of  wearing,  i.  270. 
Urinary  antiseptics,  ii.   372. 
Urinary  fever,  i.  289. 

acute  type  of,  i.  293. 

chronic  type  of,   i.  293. 

clinical  types  of,  i.  291. 

paracentesis  and,  i.  265. 

treatment  of,   i.   294. 
Urinary  hesitancy  or  stammering,  i.  254. 
Urinary   pouches,  ii.   338. 
Urinary  retention,  calculus  due  to,  ii.  83. 
Urination.     See   Micturition. 
Urine,  acetone  in,  i.  86. 

albumin  in,  i.  76. 

albumose  in,  i.  78. 

analysis  chart  for,  i.  72. 

bacteriology   of,   i.    110. 

bile   pigment  in,  i.   88. 

carbohydrates  in,  i.  79. 

carbonates   in,  i.   90. 

casts  in,  i.   104. 

changes   in  amount   of,   i.   271. 

changes  in  character  of,  i.  277. 

character  of,  i.  303. 

chemical  examination  of,  i.  76. 

chlorids  in,  i.  89. 

cloudiness    in,   i.    73. 

color  of,  i.  72. 

composition  and  properties  of,  i.  71. 

diacetic  acid  in,  i.  86. 

epithelia  in,  1.   100. 

examination  of,  i.  317. 

kidney   disease   and,   i.   369. 

Fehling's  test  for  sugar  in,  i.  79. 

fermentation  test  for,  i.  87. 

fibrin  in,  i.  78. 

general  considerations  of,  i.  70. 


Urine,  glucose  in,  i.  79. 

hippuric  acid  in,  i.  86. 

in    chronic    parenchymatous    nephritis,    i. 
424. 

in  hemoglobinuria,  i.  88. 

indican  and  other  ethereal  sulphates  in,  i. 
87. 

inorganic  constituents  of,  i.   89. 

leucin  and  tyrosin  in,  i.  89. 

jnassage   products  in,  i.    109. 

melanin  in,  i,  89. 

microsco^iical  examination  of,  i.  92. 

mucin  in,  i.  79. 

mucus  in,  i.  79. 

Nylander's  test  for  sugar  in,  i.  80. 

obtaining  of,  at  examination,  i.  313. 
from  female  patients,  i.   321. 

odor  of,  i.  73. 

organized  sediments  in,  i.  99. 

perspiration  compared  with,  i.  437. 

phenyl-hydrazin  test  for  sugar  in,  i.  81. 

phosphate  crystals  in,  i.  97. 

phosphates   in,  i.   90. 

physical  properties  of,   i.   71. 

polarimetry   and,   i.    81. 

preservation  of,  i.  71. 

proteids   in,  i.   76. 

pus  in,  i.  99. 

quantitative   tests   for   sugar  in,    i.   81. 

reaction  of,  i.  74. 

residual,  prostatic  hypertrophy  and,  ii.  242. 

sediment  of,  i.   93. 

selection  of  specimens   of,  i.  71. 

serum  globulin  in,  i.  78. 

shreds  in,  i.  109. 

specific  gravity  of,  i.  74. 

stricture  and,  ii.  416. 

sulphates   in,  1.   91. 

total  solids  in,  i.  75. 

transparency  of,  i.  73. 

tuberculosis  of  kidney  and,  i.  537. 

unorganized  sediments  in,  i.  94. 

urea  and  its  compounds  in,  i.  83. 

urethritis  and,  ii.  350. 

uric  acid  in,  i.  84. 

Williamson's  test  for  sugar  in,  1.  81. 
Urinometer,  i.   74. 
Urobilin,  i.  72. 
Urochrome,  1.  72. 
Urogenital  triangle,  i.  26. 
Uromancers,  i.  2. 
Urometer,  i.   84. 
Uronephrosis,   i.   560. 

Albarran's  suturing  in,  i.  618. 

capittonage  in,  i.  618. 


INDEX 


701 


Uronephrosis,  Israel's  operation  for,  i.  G18. 
operative  treatment  of,  i.  010. 
pyelo-ureteral  operation  in,  i.  018. 
Trendelenburg  operation  in,  i.   018. 
Urotropin,  i.  554. 

in  bacteriuria,  i.  288. 
in  cystitis,  ii.  40. 
Uterine    displacements,    bladder    disturbances 
due  to,  ii.   105. 
anteflexion,  ii.  105. 
anteversion,  ii.   100. 
retroflexion,  ii.   100. 
retroversion,  ii.  100. 
micturition   and,   i.   244. 
Uterine    epithelia,   i.    104. 
Uterus,  gonorrhea  and,  ii.  511. 

Vaccine   therapy,   gonorrhea   and,   ii.    514. 

Vaginal  epithelia,  i.  104. 

Vaginal   irrigation,   i.  34.3. 

Vaginal  and   perineal  hernias   of   bladder,  ii. 

31. 
Vaginitis,  i.  302, 
Van  Helmont,  i.  2. 

Van  Hook's  uretero-ureterostomy,  i.  059. 
Varicocele,  diagnosis  of,  ii.  042. 

etiology  of,  ii.  042. 

examination  of,   ii.   042. 

prognosis  in,  ii.  643. 

symptoms  of,  ii.  642. 

testicular   atrophy  from,   ii.   587. 

treatment  of,  ii.  643. 
Vas  deferens,   i.   61,   63. 
Vasa  efferentia,  i.  58. 
Vascular  tumors  of  penis,  ii.   527. 
Vegetables  in  diet  of  urological  cases,  i.  326, 
Venereal  warts,  treatment  of,  ii.  542. 
Venesection,  uremia   and,  i.   451. 
Vermiform    appendix,    bladder    disturbances 

due  to,  ii.   123. 
Verrucse  acuminata?,  treatment  of,  ii.  542. 
Vesical  calculus,  Bigelow's  method  of  remov- 
ing, ii.  92. 

children  and,  ii.  94. 

colpocystotomy  for,  ii.  94. 

course  of,  ii.  87. 

cystitis  from,   ii.   88. 

cystophotographs  of,  ii.  89. 

cystoscope  and,  ii.  89. 

diagnosis  of,   ii.  88. 

encysted,  ii.  84. 

etiology   of,    ii.    83. 

fracture  of,  ii.  87. 

frequency   of  urination   in,   ii.   86. 

hematuria  in,  ii.  80. 


Vesical  calculus,  hemorrhoids  and,  ii.  87. 

immobile,  ii.  85. 

in  Italians,  ii.  84. 

in  women,   ii.  94. 

inguinal  hernia  and,  ii.  87. 

Htholapaxy  for,  ii.  92. 
perineal,  ii.  93. 

lithotomy  in,  ii.  93. 

lithotrity   for,   ii.   92. 

nationality  and,  ii.  84. 

pain  in,  ii.  80. 

pathology  of,  ii.  84. 

perforation  by,  ii.  88. 

radiography  in,  ii.  89. 

symptoms   of,   ii.   86. 

treatment  of,   ii.    91. 

urine  in,   ii.   86, 
Vesical  fistula,  ii.  43. 
Vesical    papillomas    from    improper    use    of 

cystoscope,  i.  207. 
Vesiculse   seminales,   i.   63. 
Vesiculitis.     See  Seminal  Vesiculitis. 
Viglia's  discovery  of  urinary  casts,  i.  4. 
Volkman's  operation  for  hydrocele,  ii.  581. 
Vomiting  and  distention,  prostatectomy  and, 

ii.  303. 
Vulvo-vaginitis   in    children,    ii.    513, 

Wafer  chancre,  ii.  536,  077. 

Wallace,  quoted,  ii.  232. 

Wappler's  controller  for  urethroscopy,  i.  190. 

Ward  dietary,  i.  328. 

Wassermann  reaction,  salvarsan  and,  ii.  719. 

Water,  use  of,  for  solutions,  etc.,  i.  157. 

in  urology,  i.   341. 
Water  diet  in  urologj^,  i.  337. 
Waxy  casts,  i.   107. 
Weir-Mitchell  cure,  i.   415. 
Wet  packs,  i.  345. 
White  and  Martin  on  iodids,  ii.  714. 
on  sterility,   operation  for,   ii.  615. 
Willy  Meyer  sterilizer,  i.   154. 
Wiseman,  Richard,  i.  2. 
Wolffian  fubules  and  duct,  i.  59. 
Wounds  of  kidney,  i.  399. 

X-Ray,   for   bladder  affections,  ii.   7. 
for  gunshot  kidney  woiuids,  i.  400. 

Yeast  cells,  i.  115. 

Young's   operation   of  prostatectomy,  ii.  281. 

Young's   retractor,   ii.   283. 

Ziehl-Neelsen     method    of    staining    tubercle 

bacilli,  i.  113. 
Zuckerkandl's    operation,    for    prostatectomy, 

ii.  281. 


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